The Three Essays on The Theory of Sexuality Revisited

The word on the street is that psychiatry has lost the mind in its quest for the brain. Is discussing this paper going to change that? My task is simply overwhelming. First, I will review the essay. Then, I will find my teaching points.

According to Freud, this essay was his second most important work (the first being The Interpretation of Dreams). In this essay he states that sexual tension promotes development from infancy through adulthood. For turn of the century Vienna, this was a revolutionary concept. He describes that the sexual experiences from 0-5 create the underpinnings of personality, yet are also sequestered from narrative memory. At 5, the child enters a period called latency in which dams in the form of disgust, shame and morals, allow the child to enter into a period of learning at school. Freud, ahead of his time, said that these dams are "organically determined". In essence, our DNA (yet to be discovered) creates a latency period so that a child can learn in school and not be preoccupied by sexual urges. This sexual energy gets buried and then resurfaces in the form of productive activities. Freud calls this reaction formation and sublimation.

His evidence that sexual forces occur throughout life is based on the child's way of self-soothing. He points to thumb-sucking as an example of a rhythmic repetition of a sucking contact by the mouth. The baby has transformed the location for nourishment into the location for sensual pleasure. This constitutes the oral phase of development. Likewise, the anal zone is transformed from an area responsible for somatic functions into an area where control can be exerted and the child can feel a sense of power.

Children can find sexual pleasure in a variety of ways. Freud said that children have a "polymorphously perverse disposition". Instincts can center around an erotogenic zone such as the mouth or the anus, or it can be a component instinct where the child is sexually excited by looking at other people (voyeur) or by having other people look at them (exhibitionism). Children are also extremely curious about sexual activities. Freud called this "the sexual researches of childhood". In this "sexual research" boys try to find out why they are different than girls. In so doing, boys realize they have a penis and that this is so precious that they then develop castration anxiety. Girls, on the other hand, realize they don't have a penis and so, according to Freud, they develop penis envy. These feelings quiet down as the child enters school-age, but then resurface in puberty. Freud calls this trajectory "diphasic".

Freud was the first one to describe how children experience sexual pleasure. This sexual pleasure comes in the form of mechanical excitations. For example, children love being thrown up in the air and they love to rock. The thrill of a child's rocking horse would be another good example. The familiar play of "rough housing' would be another example of a child's sexuality. Further, Freud goes on to say that feeling states are innately sexual. The child's fear is a source of sexual excitement in that jumping from high up creates fear followed by a sense of mastery in a parallel way to sexual activity. Finally, he says that passion about intellectual work is also a form of sexual satisfaction.

An interruption....a drug representative for Abilify comes to my office....I happily take some samples...I am invited to a dinner program chaired by my highly esteemed colleague.....I return to thinking about Freud and sexuality.....the mind and the brain converge.

The ever-present force of sexuality is described in this 1905 paper. Our skin and our sense organs are stimulated and we are excited. Certain areas are particularly excitable and these are termed our erotogenic zones. Pleasure can end and pain can begin when the intensity exceeds our tolerance. Freud then does self-promotion. He touts the "novelty" of his approach to this sensitive subject of child sexuality. Although lacking in humility, Freud importantly reminds us that there are varieties of sexual constitution. That is, each person is different (thanks to our DNA-which again, the discovery came after his time). Second, that sexuality and bodily functions are forever linked and that disorders of the body (such as Irritable Bowel Disorder) could result from sexual excitation which cannot find a suitable outlet and so the energy gets turned towards an organ.

So, I conclude by asking myself what I want these residents to learn from this "classic" article. First, I want them to read Freud like great literature. In fact, Freud won the Goethe prize. Second, I want them to see motivation as a complicated force, which in no small measure is determined by sexual energy and our pre-programmed need to reproduce. Finally, I want them to think developmentally, both that childhood history is always important to adult assessment, but in particular, I want them to think about the adult patient in terms of how his sexual needs were dealt with as a small child. This way of thinking might help them understand the underpinnings of their patient's symptoms.

Abilify helps a lot of patients be "more able". Psychoanalytic thinking does likewise.

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