This was published in 1982 by Jeremy Agnew, in the AMERICAN JOURNAL OF PSYCHOTHERAPY Vol. XXXVI, No. 4
Dr. Joanne Denko coined the word klismaphilia to describe the practices of some of her patients who enjoyed the use of enemas as a sexual stimulant. Since then questions occasionally appear in the professional literature asking about the relationship between enemas and sexual pleasure. This paper considers some of the physiological aspects of the human sexual apparatus that relate to anal sensitivity and explores why klismaphilia can be sexually gratifying.
The paper starts with a discussion of the physiological basis for anal sensitivity and anal masturbation in both the human male and the human female. The paper then goes on to relate all this to the sexual sensations received from an enema, and discusses the similarities and differences between all these types of stimulation.
Some of the psychological aspects of klismaphilia are also considered in relationship to the physiology involved. The paper concludes with a brief discussion of masked anal masturbation among the population at large.
Klismaphilia, or the use of enemas for sexual stimulation, is a practice enjoyed by a certain segment of the population, both male and female. This paper explores some of the physiological factors that are present in the human sexual apparatus that explain why this type of activity is sexually gratifying.
While researching material for another project, the author came across two articles by Joanne Denko concerning klismaphilia In these papers, Dr. Denko discussed several patients for whom the use of enemas was a sexual preference. Also, over the past several years, there have been not infrequent questions in the professional literature asking why patients derive sexual pleasure from enemas. While continuing research, the author came across further material that may help to provide the psychotherapist with a better perspective on this type of sexual activity.
By way of an aside, the use of enemas is certainly not new. The enema was known and widely used as far back as the Egyptians, Sumerians, and Mesopotamians. Enemas in the past have been used for diverse purposes, not all of them strictly medical, including being one of the ways of exorcising devils from hysterical (in the psychological sense of the word) women in 16th-century France.
During the 17th and 18th centuries, in particular, the use of the enema was very popular. References to enemas appeared extensively in 17th century plays, poems, literature, and paintings. In a way the enema, or clyster as it was then called, became a part of the pornography of the period. In medical practice of the 17th and 18th centuries, the use of the enema was as common as the use of the hypodermic syringe today. By the beginning of the 19th century, this enema fad seemed to have waned somewhat, possibly partly as a result of the introduction of drugs for laxative purposes.
To understand why the use of enemas has sexual appeal to some people in contemporary society, it is necessary first of all to digress slightly and to discuss anal masturbation, and to relate this to some of the physiological aspects of human sexuality.
Current interest in sexual activities that have previously been considered deviate, or at least bizarre, can be traced to recent sociological changes. The new waves of sexuality and liberalization of ideas about sex that have swept the country in recent years have brought many previously taboo areas out of the Victorian closet. Many of the old conventions and social taboos have been subject to a new examination, especially by younger adults. Society has become more tolerant about what was previously taboo or was considered “perverted” or “abnormal” sexual activity. This has resulted in exploration of new methods of sexual stimulation, one of which has been anal activity.
In the privacy of the bedroom, both intravaginal and intrarectal insertion of various objects for the purpose of sexual stimulation has become more accepted and utilized. Such sexual experimentation has resulted in discovery and utilization of anal sensitivity in heterosexual, homosexual, and autosexual activities.[13-15]
Manipulation or insertion of objects into the anus or rectum can be used to induce sexual feelings, similar to genital manipulation for sexual excitement and gratification. Anal masturbation, as this is termed, is usually performed in conjunction with genital masturbation, but may also be performed independently. The fact that this is becoming more prevalent can be judged from reports in the literature which discuss some of the mishaps that have occurred during anal masturbation.
For example, Benjamin et al. list the following cases of some unusual objects that had to be removed from the rectums of patients following masturbatory activity:
(a) A 28-year-old male who was masturbating anally with a turnip and lost control of it.
(b) a 68-year-old male who was masturbating using a water glass that became lodged in his rectum.
(c) A 27-year-old male who inserted a light bulb into his rectum and was moving it back and forth in a manner similar to prostatic massage, when he lost control of it.
(d) A 76-year-old male who inserted a carborundum sharpening stone into his anus, but lost his grip and it vanished into his rectum.
(e) A 38-year-old male who was masturbating with an 8-inch-long toothbrush holder that became lodged in his rectum.
The use of foreign objects to stimulate the rectum is not limited to autosexual activity. Daffner reported on the case of a 22-year-old male who had a soldering iron handle lodged high in his rectum. During sexual foreplay, his female partner inserted it into his rectum to intensify stimulation; however, she lost control of the handle and couldn’t remove it.
Lucas and Ryan mention the removal of objects such as soft drink bottles, a steer’s horn, cucumbers, apples, hard-boiled eggs, and a broom handle from various patients’ rectums. Chenet and Cameron mention the problems encountered by a 42-year-old male who inserted an entire carbonated beverage bottle into his rectum and, not surprisingly, couldn’t remove it. Other objects mentioned in the literature as having been removed from male and female rectums include cocktail swizzle sticks and plumber’s aids . Heterosexual Anal Activity
As well as the primarily autosexual activities discussed above, anal activity is also used as an adjunct to heterosexual activity, during foreplay and intercourse. There is a definite physiological basis for this anal eroticism and this is what will form the basis for this discussion of klismaphilia.
In the human male and female, the anus and the genitals lie in close proximity. Both the anal and the perineal areas are richly supplied with sensory nerve endings, and are highly sensitive to tactile stimulation. Also the anal and genital areas share muscles and nerves and therefore, stimulation of one area may cause a reaction in the other. For example, during foreplay, stimulation of the genitals in either sex may cause the anus to contract. Contraction of the anus upon manipulation of the clitoris during physical examinations is well known among gynecologists. The converse is also true. Stimulation of the anus may bring about sexual excitement. Tightening of the anal sphincter, either voluntarily or by erotic stimulation, may bring about contractions o f the muscles that extend into the genital area, producing erection in the male and movement of the clitoris in the female.
Physiologically, this is to be expected. In both the male and the female the bulbocavernosus muscle is attached to the external anal sphincter by the central tendon of the perineum. In the male, the bulbocavernosus muscle ensheaths the penis and assists in its erection (as well as expulsion of semen at orgasm); in the female, this muscle surrounds the orifice of the vagina and continues up to the clitoris, where it assists in clitoral erection. In addition, the ischiocavernosus muscle stretches from in front of the genitals in both sexes back into the perineal area. The perineal branch of the pudendal nerve supplies both muscles.
This effect of stimulation/reaction of the two areas forms the physiological basis for the phenomenon of involuntary penile erection sometimes described by hospitalized male patients (usually much to their embarrassment) when the rectal tube is inserted during an enema procedure.
The best-documented study of genital/anal interaction during sexual activity was performed by Masters and Johnson in their classic study of human sexuality. They report that involuntary contraction of the anal muscles and sphincter occurs in both sexes as part of orgasm. In the male, the anal sphincter contracts rhythmically from two to five times as part of the violent muscular contractions that force semen through the urethra as the culmination of the sex act. Semen is forced through the urethra by contraction of the bulbocavernosus muscle; so, naturally, contraction of this muscle would cause the external anal sphincter to contract by coupling through the common tendon. In the female, two to four contractions of the external anal sphincter and the muscles of the perineal area occur in parallel with orgasmic muscular contractions in the vagina. Again, this would be expected because of the coupling between the muscles.
Further work on anal sensitivity was reported by Masters and Johnson during their studies of homosexuality. They reported that females penetrated during rectal intercourse reached orgasm during 11 out of 14 occasions, with three multi-orgasmic experiences reported. Similar to vaginal intercourse, they noted that the female anal sphincter contracted in simultaneous rhythm with contractions in the vagina.
In an earlier study, Kinsey et al. also reported that some individuals found anal stimulation definitely erotic and that a few reported being brought to orgasm by this type of simulation.
Because of the abundance of sensory nerve endings, the anal and perineal areas are highly sensitive to tactile stimulation and manipulation of these areas may produce considerable erotic arousal. Some people, both males and females, are as erotically aroused by anal stimulation as they are by genital stimulation and, in some cases, anal stimulation produces greater arousal.
Stimulation of the anus has been well known as part of the prelude to intercourse. Some women enjoy having the anus stroked or lightly rubbed during foreplay or intercourse; some enjoy a finger inserted into the anus during intercourse.,, Voluntary contraction and relaxation of the anal muscles is often used by both sexes to intensify sexual feelings. A finger, or sometimes other small objects, inserted into the anus during intercourse is reported to intensify the orgasmic experience for many men and women.[28- 30] The practice of prostitutes inserting a finger into the anus of male clients to induce an erection and to speed up intercourse has been reported in the literature., Kinsey et al. noted that the perineal area is sensitive to pressure an d that many males may be quickly brought to erection when pressure is applied in the area between the anus and the scrotum.
The conclusion is that the anus is a highly sensitive and erotic area for some, but certainly not all, people. Statistics in this particular area are hard to find; however, McCary states that about half of all men and women report they experience erotic reactions to some form of anal stimulation. Hunt says that well over half of males and females under 35 years of age have experienced with touching or inserting a finger into the anus during foreplay. Kinsey et al. feel that as many as half or more of the population may find some degree of erotic satisfaction in anal stimulation.
The step beyond manual stimulation of the anus is insertion of the penis into the rectum as a form of heterosexual activity. This is reported to be enjoyed by some women. Though again statistics are somewhat hard to find and may be somewhat anecdotal, The Redbook Report on Female Sexuality says that of those they surveyed 43 percent had tried anal sex at least once. Of the total survey, 2 percent said they did this often; 19 percent said they did it occasionally. Of those who had tried it, the feelings toward anal sex were about evenly divided: 41 percent said it was very enjoyable or somewhat enjoyable; 49 percent said it was unpleasant or repulsive; the other 10 percent had no feelings either way.
Hite reported that 11 percent of her survey enjoyed anal intercourse, though her statistics are somewhat difficult to interpret since her questionnaire was changed three times during the course of the survey. Hite’s report also describes some anal masturbatory activity, including insertion of a finger, douche nozzle or enema tube, as part of clitoral masturbation. Similar activity has been described by Caprio.
In the professional literature, Bolling reported that in a survey of routine gynecological patients, 25 percent had participated in heterosexual anal intercourse one or more times. Of this study group (n = 526), 8 percent enjoyed it and used it regularly.
Though it may not seem so at first, rectal intercourse has certain physiological similarities to vaginal intercourse, as far as producing potentially erotic sensations. The entrance to the anus, like the entrance to the vagina, is richly supplied with nerve endings, many of which are shared in common, along with nerve endings of the entire perineal area.
Though there is a rich supply of tactile nerves around the anal sphincter, the interior rectal walls, unlike the interior of the vagina, do not have sensory nerve endings. Interior probing of the rectum cannot be felt directly. The extreme example of this is the fact that trauma or perforation of the rectum can occur without the patient having any pain sensation.
However, even though the rectal mucosa does not have direct sensory nerve endings, it is still possible to receive sensations from deep penetration of the rectum. During anal intercourse, both men and women report feeling erotic sensations from deep penetration of the rectum, the women reporting these sensations to be similar to those experienced during deep vaginal penetration. These sensations may be due to one or a combination of three factors.
First, erotic stimulation is possibly due to thrusting pressure on other internal organs interpreted as coming from surface stimulation by the process of referred sensation, similar to the phenomenon of referred pain. Nerves in the pelvic plexus are distributed via secondary plexuses to all the pelvic viscera. Because there are relatively few receptors in the abdominal viscera, nervous sensations are poorly localized. From a muscular standpoint, the subcutaneous fascia of the abdomen is continuous with muscles of the thighs and external genitalia.
Secondly, rectal penetration indirectly stimulates perineal muscles, nerves, and other structures. For example, in the female, rectal intercourse may cause indirect stimulation of the clitoris by traction on the labia minora, in the same way that a woman’s anus is usually stimulated by traction on vaginal tissues during vaginal intercourse. In the female, this may also result in direct stimulation of the internal genital orgasms. During rectal examinations, the posterior wall of the vagina and fornix can be felt. By reaching further, the cervix and the body of the uterus can also just be felt.</A. In the male, rectal intercourse results in pressure on and stimulation of the prostate gland, which is located on the other side or the anterior wall of the rectum. Masters and Johnson have reported that males who acted as the passive partners during rectal intercourse could not reach orgasm without additional manual masturbatory activity, though there was presumably gratification of the sexual urge through stimulation of the anal and perineal structures, which forms the basis for the passive homosexual role. Interestingly, Masters and Johnson report that sensitivity of the rectum to stimulation is essentially the same for both men and women.
A third factor is that there is some direct stimulation of the rectum itself. The rectal walls do have interceptive and stretch receptors that are activated by fullness as part of the defecation process. Rectal penetration may stimulate these receptors and cause deep erotic sensations. Kinsey et al. noted that, in the female, strong pressure applied from inside on the posterior wall of the vagina may stimulate these receptors and nerves.</A. They said that this may be one of the sources of satisfaction which many females experience during intercourse. Some women even prefer certain positions for intercourse, because in them the penis presses back against the rectum and provides additional stimulation.
Though all this is a physiological phenomenon, it also ties in with accepted psychological thinking. The psychological phases of libidinal development are well known. The general trend is from the oral stage, through the anal stage, to the phallic stage. During the anal stage of development, which is generally considered to occur around 11/2 to 3 years of age, the important body zones are the organs of elimination, the anus, the rectum, and the bladder. Pleasurable sensations are connected with the acts o f defecation and urination and are often induced on purpose by the child. Later on there is also a realization of pleasurable sensations associated with retention of these byproducts.
In essence, then, the key points of the foregoing discussion can be summed up quite concisely. The anus contains a rich supply of sensory nerve endings and easily stimulated touch receptors, similar to the external entrance to the vagina. This, in conjunction with the nerves and muscles shared between the genitals and the anus, make the anal area a source of erotic arousal and intense sexual feeling for some people. As has been discussed, a variety of objects may be, and are, used to provide stimulation o f the anus and thus indirectly provide genital stimulation and highly erotic feelings.
After this circuitous route, this brings us back to klismaphilia and the use of enemas. To put it simply, klismaphilia appears to be a type of anal masturbation that stimulates intensive sexual feelings in some individuals. Kinsey et al. in their report on the human female mention the use of enemas and anal insertion as masturbatory techniques. Chideckel discusses the use of enemas by women for anal masturbation. Kaplan mentions the case of a female patient who gave herself daily enemas and derived in tense sexual pleasure from them.
The use of enemas meets all the qualifications for anal masturbation. The insertion of the rectal nozzle or tube provides stimulation of the anal sphincter and the muscles and nerves of the peripheral mucosa. Injection of the enema solution, though it is not directly felt by the rectum, stimulates interoceptive and stretch receptors in the terminal colonic walls, due to distention of the rectum by the increasing pressure of the enema solution. Receptors in the walls of hollow abdominal viscera are especially sensitive to distention.
In the female, as noted above, pressure on the back of the vagina can stimulate the same set of nerves and produce the same erotic experience as deep penetration of the rectum. This is one way of obtaining sexual gratification from an enema. The increasing pressure caused by the filling and distention of the rectum as the enema solution is injected, causes pressure on these same nerves and sensitive stretch receptors and this produces a similar sexual sensation.
In the male, the anterior wall of the rectum is next to the prostate and seminal vesicles. Filling and dilating the rectum with enema solution will cause direct pressure on these structures, as well as causing stimulation of the rectal stretch receptors.
Also, not to be forgotten is that the muscles stimulated by peristalsis and defecation terminate in the perineal area, as well as being loosely connected to the genital muscular structure by the close proximity of the terminal colonic segment and the internal genital structure in the abdomen. Thus expulsion of the enema can provide further erotic sensations through stimulation of the genital muscular structure by causing intensified waves of peristalsis.
The use of extra-large volumes of enema solution and the injection of highly irritating substances to produce pain and cramps belongs more in the psychological category of masochism and is left to analysis by professional therapists. However, it may be noted in passing that the intense peristalsis caused by irritating enema solutions may provide erotic stimulation for these people by the contraction of the same perineal and colonic muscle structures described above.
In the pregnant female, part of the reason for an enema in preparation for childbirth is that peristaltic waves will help stimulate contraction or the uterine muscles and speed up the birth process.,
Since we can conclude that some people enjoy and receive sexual stimulation from this type of anal activity, it is just as important to consider why it is that others do not. Since everyone has an anus and rectum, why is this type of activity not pleasurable to everyone? This is a very difficult question and one that, as yet, has no satisfactory answer. Most answers that have been put forward have to remain somewhat in the realm of speculation and theory.
Both psychological and physiological factors are probably at work here. Just as other physiological and psychological differences exist in the population as a whole, not all people find anal stimulation desirable or even tolerable. As should be no surprise, the perineal nerve supply, the perineal and perianal muscle structure, or some other physiological factor or factors are different in different people. Some people are genuinely not erotically sensitive in this area.
The psychological aspects of negative feelings about enemas and anal activity probably revolve around the fact that the anus is related to defecation and is considered taboo or “unclean” by upbringing and general social convention. Most people have aesthetic or other psychological blocks about sexual activity and sexual feelings in such a socially unacceptable area.
Past experiences with enemas will also form the basis for negative feelings about this type of activity. Most people experience enemas in a medical context and, to them, enemas are associated with illness or perhaps a stay in hospital that was not pleasant. Women may associate an unpleasant enema with the preparatory activities associated with childbirth and its allied pain, loss of privacy, and other real or imagined indignities. None of these situations could be associated with eroticism or pleasurable sexual activity.
Finally, in some people, for some reason, the individual’s potential for feelings of pleasure may have not developed. They may not have discovered their anal erotic sensitivity.
The first part of this discussion concentrated mainly on the physiological aspects of klismaphilia and sexual stimulation. Undoubtedly there are other psychological factors that are associated with klismaphilia and which may have been part of the original predisposition of an individual to klismapllilic tendencies. Unfortunately for analysts, the reasons for this particular direction of sexual development does not appear to be known.
The majority of psychological thinking relates those who have klismaphilic tendencies to enemas given early in life, typically in the 4-to-8-year-old category, though this sensitivity has also been reported to develop later in life. Patients in therapy re late that the discovery of pleasurable feelings often appeared after the chance administration of an enema during childhood. Possibly we can surmise that the basic physiology was there and the childhood experience of an enema for medical purposes merely played a role in the discovery of this sensitivity. However, not all children who had enemas in childhood necessarily show the tendency to anal eroticism in later life. ,
It can probably be concluded that predisposing factors, such as physical development (for example, a suitable muscle structure or nerve supply in the perineal and perianal area), coupled with anal stimulation (i.e. by childhood enemas) and perhaps with as yet unknown psychosexual or physiosexual factors at a sensitive psychological stage of development, can lead to a development (or perhaps only to a discovery) of anal sensitivity that can be exploited in later life as part of heterosexual, homosexual or autosexual activities.
Chideckel relates the experience of girls being given enemas during childhood and disliking them, then later coming to find them pleasurable, and finally, in adult years, taking enemas for sexual stimulation through anal masturbation. A similar pattern of development is discussed by Yates.
Children often think the anus is part of the sexual apparatus, some believing that this is the channel through which babies are born. This sexual association, coupled with arousal of unknown and possibly positive erotic feelings during the enema procedure, could form a lasting impression. An interesting discussion of several cases of children and early enema experience is related by Freytag. Caprio devotes several pages to discussion of two male patients, one of whom received enemas during childhood and the other who gave himself enemas and practiced anal insertion while masturbating to enhance sexual pleasure.
By contrast, these generalizations may be too broad. Denko reports not finding a pattern of early life experiences that explain the tendency to anal eroticism. Masked Anal Activity
There is one final physiological point that should be considered, and a few comments made about masked anal masturbation.
Among the American people there seems to be an obsession with the state of the bowels. Over-the-counter sales of laxatives are phenomenal and almost every home medicine cabinet contains an enema syringe. Excluding those who suffer from constipation due to pathological conditions, the use of frequent enemas and suppositories by bowel-conscious individuals can be considered a form of socially acceptable anal masturbation. Psychologists refer to this unconscious gratification of anal eroticism as masked anal masturbation. Caprio mentions that neurotics suffering from chronic nonpathological constipation have been known to possess a strong anal erotic component.
Denko and others in the literature note that many klismaphiliacs feel guilty about their behavior. They feel that it is socially unacceptable, that they are the only ones who indulge in it, and, due to association with the anus and defecation, that it is “dirty” or “shameful.” The individual who takes frequent enemas “for constipation” may be unaware of his or her desire to resort to anal masturbation and rationalizes these enemas as medically necessary.
Men who go to urologists for prostatic massage are indulging in another form of unconscious gratification of anal eroticism. Again eliminating those who need this treatment for pathological conditions, for the remainder this can be a socially acceptable form of medical treatment that produces anal stimulation with no guilt feeling for the individual.
For others, colonic irrigations (so-called “high enemas”) serve the same purpose. Many people enjoy colonics sexually either consciously or not., A series of colonic irrigations for general well-being is frequently given and most health-food stores have books or references on colonic irrigations and the use of enemas during fasting.46 The majority of medical opinion is that colonic irrigations for general well- being serve no particularly useful purpose; however, articles promoting their use are still published. While it is not the place of this paper to debate the medical merits or demerits of colonic irrigation, such services would not be provided unless there were a demand for them. A look in the yellow pages of the telephone book of most major metropolitan areas will reveal several sources of colonic therapy, often among chiropractors, naturopaths, and physical therapists.
The gratification of anal eroticism may be perfectly unconscious and may even be achieved by “conventional” means. For example, as noted above, some women prefer intercourse in certain positions because the penis presses back on the rectum. Even though they may profess no anal eroticism, these women could be loosely categorized as enjoying a form of rectal eroticism.
For the ones who recognize their anal eroticism, anal intercourse is a form of female masturbatory activity, even though performed in a heterosexual context. Dilation of the anus and the rhythmic motion of penile thrusts in the rectum are similar motions to those described by practitioners of female anal masturbation. The passive partner in male homosexual intercourse is obviously enjoying the same type of anal stimulation.
To sum up then, the highly sensitive tactile nature of the anal and perineal areas make the anus a source of intense sexual stimulation for some people. Klismaphilia, or the use of enemas for sexual purposes, is a form of anal masturbation that is practiced and enjoyed by some people, both male and female. As the liberalization of traditional ideas about sex continues, and the current climate of sexual experimentation continues, the therapist is probably more likely to run into references about this type of activity.