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SEXUAL MEDICINE HISTORY
Sigmund Freud and His Impact on Our Understanding of Male
Sexual Dysfunctionjsm_1332 2332..2339
Uwe Hartmann, PhD
Hannover Medical School, Clinical Psychology, Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover,
Germany
DOI: 10.1111/j.1743-6109.2009.01332.x
ABSTRACT
Introduction. Sigmund Freud was one of the most influential thinkers and theorists of the 20th century. His
groundbreaking work laid the foundation to many concepts and theories relevant to modern sexual medicine.
Aim. To evaluate Freud’s approaches to the understanding of male sexual dysfunction both in their historical context
and with respect to their significance for contemporary research and therapy of sexual problems.
Methods. After a brief biographical sketch, two of Freud’s writings, the widely acclaimed “Three Essays on the Theory
of Sexuality” from 1905, and a short article entitled “The Most Prevalent Form of Degradation in Erotic Life” from
1912, were analyzed, especially for their relevance to present treatment concepts of male sexual dysfunction.
Results. In Freud’s clinical practice “psychical impotence” was a highly prevalent complaint. In his view, this
dysfunction was caused by an inhibition due to an unresolved neurotic fixation leading to an arrest of the libidinal
development. The result is a splitting of the tender and the sensual dimension of sexuality, most notably in the
so-called madonna–whore complex. The degree of this dissociation (total or partial) determines the severity of the
ensuing sexual dysfunction. In Freud’s rather pessimistic view, the erotic life of civilized people tends to be
characterized by some degree of this condition.
Conclusions. While some of Freud’s theories are obsolete today, many parts of his work appear to be astonishingly
modern, even in the light of current neurobiological research and recent models of sexual dysfunction. Above all,
Freud was an extremely gifted observer of human behavior who shows us that in many cases, sexual dysfunctions
are no isolated phenomena, but have their roots in biographically based intrapsychic or interpersonal conflicts.
Hartmann U. Sigmund freud and his impact on our understanding of male sexual dysfunction. J Sex
Med 2009;6:2332–2339.
Key Words. Sigmund Freud; Etiology of Male Sexual Dysfunction; Madonna-Whore-Complex; Intrapsychic Con-
flict and Male Sexual Dysfunction; History of Sexual Medicine
Introduction
In 2006, the 150th birthday of Sigmund Freud,
and, in 2005, the 100th anniversary of the pub-
lication of Freud’s famous “Three Essays on the
Theory of Sexuality” [1], for many one of his
boldest and most impressing contribution to sex-
ology or sexual medicine, were celebrated. It was
Freud’s intention to establish the psychoanalysis
not only as a part of the medical science, but as a
comprehensive heuristic method that should make
a new and unique contribution to the understand-
ing of the conditio humana. By its transversal
approach, psychoanalysis could contribute new
concepts to many fields of knowledge and per-
formed a profound influence on literature, phi-
losophy, and forming art. Freud’s thinking is thus
deeply interwoven into the texture of modern
culture [2], and in a certain way, we are all
Freudians when we speak of neurosis, repression,
narcissism, or Œdipus complex.
Although Freud’s groundbreaking work took a
profound influence on science and culture, for
most of the researchers and therapists involved in
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contemporary sexual medicine, Freud’s theories
and treatment strategies appear to be hard to
understand, strange, sometimes even antiquated,
or lacking in practical relevance. This applies
particularly to those colleagues who have no psy-
chological or psychiatric background. In this con-
tribution, an attempt shall be made to evaluate
Freud’s approaches to the understanding of erec-
tile dysfunction both in their historical context
and with respect to their significance for modern
sexual medicine. After taking the reader on a short
walk through Freud’s life, some of his most impor-
tant theories, concepts, and discoveries pertaining
to male sexual dysfunction will be focused.
A Short Walk through Freud’s Life
Sigmund Freud was born on May 6, 1856 in
Freiberg, Moravia (today Pribor, Czech Republic)
as the first of eight children. His father was a wool
dealer by profession and considerably older than
Freud’s mother. Due to economic difficulties, the
family moved to Vienna in 1860, where Freud
spent almost the remainder of his life.
In 1873, he started to study medicine in Vienna
and completed his studies in 1881 with a doctor-
ate. After a research stay in Triest, he worked for
several years at the institute of physiology of the
Viennese university and was engaged in various
neurohistological studies. He obtained his habili-
tation in 1884, and was appointed as a university
lecturer in 1885 (Figure 1).
After marrying Martha Bernays from Hamburg,
Germany, Freud set up as a neurologist in Vienna.
Freud received essential impulses for his further
work during a study visit 1885/1886 at the clinic of
the eminent neurologist Jean-Martin Charcot in
Paris. Here, Freud’s interest in the fascinating syn-
drome of hysteria was awakened, and his shift of
emphasis on the areas of neuropsychiatry and psy-
chotherapy began to take shape. After having
tested several methods of treatment (including
hypnosis) with his hysterical patients without
success, Freud developed the basis of psychoana-
lytical treatment technology with the method of
free association. By giving up or bypassing con-
scious censorship, Freud thought it possible to
advance into a deeper truth and to uncover the
unconscious conflicts which are responsible for the
emergence of the neurotic symptoms (Figure 2).
The interpretation of dreams became another
corner pillar of Freud’s theoretical and therapeu-
tical concepts, besides the postulate of an uncon-
scious, the meaning of sexual motives, and the
phenomenon of transference. After having experi-
enced considerable hostility and isolation within
the scientific community, Freud was finally
appointed extraordinary professor in 1902, and
was able to gather an increasing number of sup-
porters around him. With some of the most
eminent of them, notably Alfred Adler and Carl
Gustav Jung, Freud later broke on matters of psy-
choanalytic theory, while others like Karl Abraham
or Sandor Ferenczi remained faithful companions
(Figure 3).
Figure 1 Freud and Martha Bernays in 1855, 1 year before
their marriage.
Figure 2 Freud at about the time the “Three Essays” were
written.
Freud and Male Sexual Disorder 2333
J Sex Med 2009;6:2332–2339
In 1923, he published “The Ego and the ID,”
the text where his highly influential structural
theory is introduced, and the old topographical
classification of conscious, preconscious, and
unconscious is partly abandoned. In this funda-
mental reconceptualization, Freud emphasized
that not only processes in the id, but also much of
the ego and super-ego are unconscious, not the
only line of Freud’s thinking which has in some
way been confirmed by modern neuroscience
(Figure 4).
Freud left Vienna in 1938 and went into exile to
London in order to escape persecution by the
National Socialists. In 1939, he died in London at
the age of 83 years of the results of a jaw and palate
cancer from which he had suffered for many years.
Freud’s Central Sexual Concepts and Theories
Due to the limited scope of this contribution, only
two of Freud’s writings, the “Three Essays” from
1905 mentioned earlier and a small text with the
remarkable title “The Most Prevalent Form of
Degradation in Erotic Life” [3], published in 1912,
actually one of the few publications in which Freud
deals directly with male impotence, are focused
upon.
It was the “Three Essays on the Theory of
Sexuality” in which Freud presented his theories of
infantile sexuality and libido development for the
first time in a comprehensive manner and in which
the conflict between drive impulses and defense
mechanisms was recognized by him as constitutive
for man. Together with the interpretation of
dreams, the “Three Essays” are the second pillar
on which the psychoanalytic theory rests. The
essays dealt with sexual aberrations, infantile sexu-
ality, and the transformations of puberty. As with
some other concepts, Freud was neither the only
one nor was he the first one to recognize the
importance and power of sexuality, and in his
essays, he credited the work of Havelock Ellis,
Iwan Bloch, Magnus Hirschfeld, and some others
[4]. But he was the first one who, like so often, tied
up loose ends and made the link to clinical symp-
toms. It took Freud several years before he fully
accepted infantile sexuality, and he continued to be
two minds about this cornerstone of his develop-
mental theory. As usual, Freud tried to derive from
his clinical experience a design for a general psy-
chology and pulled both neuroses and perversions
from the exotic and degenerated to a psychody-
namically understandable and very common con-
sequence of unmastered developmental conflicts.
For Freud, neurosis is essentially a condition in
which the person has regressed to his early unre-
solved conflicts in an attempt to dispose of unfin-
ished business. The resulting compromise then
leads to the formation of neurotic symptoms.
Neurotic symptoms are the outward, observable
manifestation of internalized, conflicting, but
unconscious object relations, putting their stamp
on a person’s sexual experience and sexual behav-
ior. Consequently, all internalized object relations
have a sexual dimension. It is important to note
that in neuroses, the libidinal or sexual energy
happens to be more or less absorbed by the neu-
rotic dynamics and is no longer available to a crea-
tive, including erotic, fully functioning way of
living.
Thus, Freud carved out a line from early devel-
opmental conflicts or deficits to the mental distur-
Figure 3 Freud (second from left) and his psychoanalytic
“comité,” among them Karl Abraham (third from left), Sandor
Ferenczi (third from right), and Ernest Jones (second from
right).
Figure 4 Freud at his desk in London in 1938.
2334 Hartmann
J Sex Med 2009;6:2332–2339
bances of adolescence and adulthood. And in this
line, sexuality plays a central role. Normal was no
longer normal, since Freud insisted that normal
heterosexuality is also an achievement, the end
point of a long and winding road and not a natural
phenomenon. This alone was a subversive line of
thinking for Freud’s time.
What made the “Three Essays” so outstanding
was not the “discovery” of infantile sexuality, but
rather that Freud succeeded for the first time to
bring different forms of expression of human sexu-
ality (infantile, paraphilic, neurotic, mature) in a
developmental perspective and in a systematic
context [5].
Eventually, the three essays remained a work in
progress for Freud. Not more than a small booklet
of some 80 pages on their first publication, they
grew to 120 pages by 1925 when they reached
their last edition during Freud’s lifetime.
The Most Prevalent Form of Degradation
in Erotic Life
Seven years after his revolutionary “Three Essays
on the Theory of Sexuality,” Freud applied these
theories in his article “The Most Prevalent Form
of Degradation in Erotic Life” to a syndrome that
he interestingly enough describes, besides the
multifaceted anxiety, as the most common disor-
der on which he was consulted by his patients. In
this article, which without any doubt belongs to
the classical writings on erectile dysfunction [6],
Freud introduced the term “psychical impotence”
into his writings and stressed the high prevalence
of this condition which is manifested by “a refusal
of the sexual organs” to execute the sexual act.
This is not only specific to the sexual act (before
or after the attempt the man may be fully func-
tional), but this failure may also happen only with
certain women. Consequently, this inhibition
seems to be due to some quality in the sexual
partner. It is no chance that this essay is part of
the cycle “Contributions to the Psychology of
Love,” as in Freud’s view, psychical impotence is
essentially a disturbance of the capability for love
(Figure 5).
In his reasoning, the disorder was due to the
“inhibiting influence of certain (unconscious)
complexes in the mind,” which are mainly charac-
terized by an unresolved fixation on the mother
leading to an arrest of the libidinal development.
Freud pointed out that, in order to be fully capable
of love, “two currents have to unite,” which he
describes as the “tender” and the “sensual”
current. In the ideal development, the adult man
still chooses his partners (in Freud’s technical
diction: objects) after the pattern of the infantile
ones, but confronted with the obstacle of the incest
barrier that has in the meantime been erected, tries
to shift his feelings to partners with whom a satis-
fying sexual life can be realized. Subsequently, he
can attach his tender feelings to the new object,
thus enabling a unity of tenderness and sensuality.
When this process is successful, “the greatest
intensity of sensual passion will bring with it the
highest mental estimation of the object.” Two
factors can obstruct this success: (i) the degree of
frustration encountered in reality with the new
object choice, and (ii) the degree of attraction that
is still exercised by the infantile objects. If these
two factors are sufficiently powerful, an unresolv-
able intrapsychic conflict emerges, and the general
mechanism of neurosis formation will come into
operation.
When “the whole current of sensual feeling”
remains unconsciously fixated to incestuous
objects, total impotence will result. In less severe
conditions, the sensual current finds some outlet,
but the sexual functioning is “capricious, easily
upset, clumsy and not very pleasurable.” Above all,
the erotic life of these men remains dissociated and
divided between the two currents, which brought
Freud to the famous formula: “Where such men
love they have no desire and where they desire
they cannot love.” In this “solution” of the devel-
opmental conflict, the principal compromise is
the degradation of the sexual object: As soon as
the sexual object fulfils the condition of being
degraded, sensual feeling can have free play, con-
siderable sexual capacity, and a high degree of
pleasure can be developed. Here, Freud alludes
to the so-called Madonna-whore-complex as the
principal form of compromise emerging from this
dissociation. In this constellation that in our own
clinical experience and in more or less attenuated
forms, is still highly prevalent in today’s patients;
sexual arousal is only possible with a sexual partner
who has in some way been degraded (the whore)
while the adequate and respected partner cannot
be fully desired (the Madonna).
Why do some men suffer from this kind of
psychical impotence while others can obviously
escape that condition? In answering that question,
Freud maintained that psychical impotence is far
more widespread than is generally supposed, and
that some degree of this condition does in fact
characterize the erotic life of civilized people.
Accordingly, Freud concluded that “it must be said
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J Sex Med 2009;6:2332–2339
that whoever is to be really free and happy in love
must have overcome his deference for women and
come to terms with the idea of incest with mother
or sister.” Here, Freud is certainly not arguing in
favor of a disrespectful behavior toward women,
but instead he tries to highlight the fact that a truly
and lasting satisfying sexual love requires that the
“wrong respect” for the other sex, e.g., in the form
of idealization, may not be too compact. Although
some kind of idealization is, on the one hand,
required to fall in love, but on the other hand, it
must be so permeable that the touch of aggression
necessary for true sexual excitement can be allowed
[7].
If this is not possible, the love life gets boring
in the best case, but more frequently, sexual dys-
functions will be the likely result. This also
implies that freedom in life and happiness in love
are bound to the “overcoming” of the Œdipus
complex that has to do more with the triangular
processes of this developmental phase than with
the contents originally stressed by Freud. For the
first time, the child must now emotionally knot
three simultaneous relations. It starts a separate
relation to every parent, and at the same time,
perceives itself excluded from the parental rela-
tionship. It must correspondingly learn to
bear ambivalence [7]. Therefore, the individual
Figure 5 Front cover of the Jahrbuch
für Psychoanalytische und Psychopa-
thologische Forschungen (Year-Book
for Psychoanalytic and Psychopatho-
logical Research) from 1912.
2336 Hartmann
J Sex Med 2009;6:2332–2339
destiny of sexuality is always simultaneously a
destiny of love.
Freud’s Impact on Modern Sexual Medicine
Looking at Freud’s significance for today’s sexual
medicine, one can easily quote his biographer
Peter Gay [2], who said that Freud is “inescap-
able.” Not only the discovery and development of
psychoanalysis as an important psychotherapeutic
school combines with his name, but by his complex
and multilayered work, Freud became one of the
most influential thinkers and theorists of the 20th
century. The complex construct of psychoanalysis
could contribute new concepts to many fields of
knowledge and performed a profound influence on
literature, philosophy, and forming art. Freud’s
thinking has thus become an integral part of
modern culture.
More than a 100 years after Freud’s first pio-
neering publications (above all the “Studies in
Hysteria” and “The Interpretation of Dreams”),
modern matter of courses like the existence of
unconscious emotional processes and contents
(which could recently be confirmed in a fascinating
way by advances in neurobiology and conscious-
ness research) or the fact that the human sexuality
does not take their beginning only with puberty or
adolescence can be hardly understood in their
explosive force at the time of their discovery by
Freud. This applies particularly to the infantile
sexuality, as well as to the role of sexuality in the
formation of neurotic symptoms. For his emphasis
on the meaning of sexual motives, Freud was fre-
quently accused of promoting a “pansexualism,” a
reproach which, at more exact knowledge of his
work, proves to be an unjustified oversimplifica-
tion [8]. In fact, Freud’s work is even characterized
by a certain ambivalence toward his bold insights
and theories, especially in the area of sexuality.
Accordingly, Freud never became a “sexual libera-
tor” like some of his followers, and did not believe
that the unrepressed expression of sexual needs
would be the ideal way to happiness or mental
health. Instead, he thought that a certain degree of
disappointment in love is unavoidable, and he was
rather convinced of the two-sidedness of sexual
repression and frustration as being the source of
dissatisfaction and—by the mechanisms of subli-
mation and renunciation—also the source of some
of the highest human cultural achievements.
Overall, Freud remained skeptical of the potential
therapeutic efficacy of sexual reforms.
However, we now know that Freud’s theories
have a number of serious flaws and are obsolete in
some respects. His thinking was revolutionary in
many ways, but conventional in others. Especially
in his writings on female sexuality, Freud proved to
be a child of his time rendering most of his con-
cepts in this field obsolete for modern sexual medi-
cine. We also know that not all sexual dysfunctions
are due to deep-rooted neurotic conflicts or ego-
structural deficits. Instead, the causation of sexual
disorders is much more varied and often simpler,
originating from sources like performance anxiety,
spectatoring, sexual myths, relationship problems,
and somatic factors. In addition, unresolved
Oedipal feelings do not have the ubiquitous role
assigned by psychoanalytic theory, but seem to be
one factor among others.
In other aspects, however, Freud’s work appears
to be astonishingly modern. It is of note that it has
largely been disregarded that Freud had worked as
what we would today call a neuroscientist for
almost 20 years before he set out to develop psy-
choanalysis. He then abandoned the popular
attempts to relate clinical syndromes to anatomical
brain structures in favor of a functional system,
which is “represented dynamically between differ-
ent brain areas.” He also thought that the outside
world is represented in our central nervous system,
and he spoke of two “perceptual surfaces.” For
Freud, the reality we perceive was always the
reality of our brain or of our inner world, a
remarkably modern perspective. One of today’s
most promising models of sexual dysfunction is the
dual-control model developed by John Bancroft
and Erick Janssen [9–11]. This model basically
says that sexual responses and the vulnerability to
sexual dysfunctions depend on dual-control exci-
tatory and inhibitory neurobiological systems. As
individuals vary in their propensity for inhibition
and excitation, an adaptive balance is crucial to
sexual functioning. Questionnaire studies yielded
one excitation factor, and, interestingly, two differ-
ent inhibition factors: (i) the first factor is a more
complex and intrinsic dimension reflecting the
basal “inhibitory tone” of a person or the degree of
inhibition the whole system is set at; and (ii) the
second factor refers to the perception of an exter-
nal threat and reflects the inhibitory responsive-
ness to perceived threats or distracters.
In an attempt at linking this model to Freud’s
thinking, one can say that both Freud and the
dual-control model propose that sexual dysfunc-
tions are due to a dominance of inhibitory forces,
and the first inhibition dimension described by
Freud and Male Sexual Disorder 2337
J Sex Med 2009;6:2332–2339
Bancroft and Janssen might reflect the inhibitory
tone the sexual system of a person is set at. Isn’t it
possible that this dimension may also be some-
thing like the substrate of Freud’s famous “Trieb-
schicksal,” i.e., the destiny of an individual’s sex
drive, of his sexual longings and needs?
Conclusion
So what can the practitioner who is challenged
with the therapy of patients with sexual problems
at the beginning of the 21st century learn from
Freud? As an extremely gifted observer and analyst
of human experience and behavior, Freud contin-
ues to show us in his laconic way that sexual func-
tion or dysfunction are not isolated processes and
very often are more than simple organic failures.
His writings clearly point to the necessity of con-
sidering and addressing intrapsychic and interper-
sonal conflicts in evaluating and treating male
sexual dysfunction. These conflicts of which some
of the most eminent are described in “The most
prevalent form of degradation in erotic life” have
not disappeared in the sociocultural transforma-
tion processes of human sexuality; they have only
changed their contours and guises since the time of
Freud. In clinical practice, it is not always manda-
tory to focus on these more deep-rooted factors
because, as is suggested by Helen Kaplan’s widely
acclaimed dual-level model of the etiology of
sexual dysfunctions [12,13], the immediate factors
causing the dysfunction in the here-and-now have
to be focused and dealt with first. In those cases,
however, where there is resistance to treatment or
who turn out to be so-called “nonresponders” to
either pharmacotherapy or behavior-oriented sex
therapy, the sexual health professional should be
alert to the biographically rooted conflicts ana-
lyzed by Freud.
Freud also was a highly talented and entertain-
ing writer, and it still is a fascinating and exciting
experience for the reader to learn that the history
of our sexuality is interwoven deeply in the fabric
of our life and specifically in our interpersonal
experiences. Only if we try to understand, together
with our patient, this complex course of desires
and basic needs, will we be able to truly help him,
independent of the therapeutic option we choose
to employ.
Acknowledgments
I would like to thank Dr. Dirk Schultheiss (Giessen,
Germany) for his ideas, his helpful suggestions, and his
patience. Adapted from an oral presentation at the
History Session of the ESSM Congress 2004 in
London, UK.
Corresponding Author: Uwe Hartmann, PhD,
Hannover Medical School, Clinical Psychology, Clinic
of Psychiatry, Social Psychiatry and Psychotherapy,
Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Tel: +49 511 5322407; Fax: +49 511 5328407; E-mail:
hartmann.uwe@mh-hannover.de
Conflict of Interest: None.
Statement of Authorship
Category 1
(a) Conception and Design
Uwe Hartmann
(b) Acquisition of Data
Uwe Hartmann
(c) Analysis and Interpretation of Data
Uwe Hartmann
Category 2
(a) Drafting the Article
Uwe Hartmann
(b) Revising It for Intellectual Content
Uwe Hartmann
Category 3
(a) Final Approval of the Completed Article
Uwe Hartmann
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