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An elderly, unsophisticated man consulted a psychiatrist because he was extremely anxious lest he might be a latent homosexual. He retained a life-long wish to establish a satisfactory heterosexual relationship. In the therapeutic setting he was coherent, anxious, guarded, and distant, and was preoccupied with a variety of
hypochondriacal symptoms. He never revealed any delusions or hallucinations, and psychotropic medications had no significant effect. There was some history of homosexual abuse in childhood. In the course of psychotherapy the patient revealed that he had practiced a form of self-sodomy throughout his life. This had become his preferred mode of sexual gratification. It seemed to protect him from the annihilative experience of intimacy with a partner of either sex. It also served the adaptive purpose of integrating the masculine and feminine identifications that the patient experienced as two separate selves, thus arresting even more extensive fragmentation of his personality. The authors emphasize the clinical importance of accepting and working with a patient's report of masturbatory practices and fantasies.