D'Amico G, Colasanti G (eds): Psychological and Physiological Aspects of Chronic Renal Failure. Contrib Nephrol. Basel, Karger, 1990, vol 77, pp 15-23
Sexual Function in Dialysis Patients Psychological Aspects G. Pietropolli Charmet University of Milan, San Carlo Borromeo Hospital, Milano, Italy
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With a view to providing data of some interest for this seminar, we have processed the initial results of one section of a more extensive research project we are conducting on the symbolic, affective and relational universe of the dialysis patient. We have put together a sample of men and women undergoing dialysis, obtaining information in interviews and clinical discussions. We considered that it would also be useful to obtain details of dreams. Our research group operates on the basis of a psychoanalytical theory, and the material we worked on therefore consists of the associations of our respondents and their dreams. We have processed the data in accordance with the symbol interpretation criteria used in modern communication analysis, with special reference to the theory of affective codes devised by Italian psychoanalyst Franco Fornari. Our sample of patients makes no pretence at being statistically significant; it is a reasoned sample, selected in accordance with qualitative research criteria. Our aim was to collect some prevalent symbolizations, i.e. some trends in the process in which the dialysis patient's way of thinking, feeling and loving develops. On the basis of the data processed, the first consideration of a very general nature is that the experience of survival through dialysis involves at least a partial loss of sexual interest. The patients we interviewed said that their erotic relationships with their sexual partners or potential partners are considerably diluted, and tend in time to dissolve. This does not necessarily mean that their sex life disappears; the motivation for meetings, actual practice and sexual intercourse wanes and fades away. What could be called occasional sexual intercourse remains, however, within a stable, established emotional relationship.
16
When considering the dominant emotion which is developed in relation to this situation, regret for the loss of a deep personal sexual motivation and the loss of spontaneous sexual desire seems to be slight; the search for pleasure or the path followed by the deep-rooted desire of the dialysis patient changes, and it is this that we have endeavored to identify. This reduction in the quantity and quality of the sex life which is actually triggered by desire is a process of a general nature in the patient's life which eventually leads the patient to invest all his/her emotional expectations in the family to which he/she belongs, bringing to it desires and fantasies which, when life is lived under less extreme conditions, are normally directed outside the family. We will now consider the quality of feelings and the intention of the sexual desire in the patient's sex life (when it exists). As sexual desire as such rarely makes a spontaneous appearance in the patient's mind and body with the force and passion of the past, as the sexual inspiration is very faint, what promotes sexual initiative towards the partner seems to be a motivational spur of a different kind. We have identified two which seem to represent the organizers of the dialysis patient's sexual initiative. The first has the result that the sexual partner is seen in emotional terms which psychoanalytically speaking could be described as depressive. In this case, the patient feels that he/she has disappointed, neglected, even `sucked the blood' of the sexual partner who is relegated to a sort of emotional and sexual backwater; the sexual initiative is a way of making amends for the neglect and oblivion to which the partner has been subjected. The `starter motor' of the sexual initiative is not desire, but a sort of odd sense of guilt for not having loved enough, for having allowed the partner's erotic expectations to age and wither. The other dominant perception, which we feel is more of a background in characterizing the patient's sexual initiative, configures the sexual partner as the repository of an avid, heedless, intrusive attitude to the patient. This is generally the perception of a female dialysis patient; they describe their partners' claims in frankly persecutional terms because of the discomfort, almost amounting to suffering, and the generally icy atmosphere in which the erotic experience takes place under these circumstances. From the psychoanalytical standpoint we feel it interesting to emphasize a factor which recurs with some frequency in the imagination of dialysis patients, in particular those undergoing home dialysis, and which was identified on the basis of interviews and the interpretation of dreams recounted by respondents.
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
Pietropolli Charmet
Sexual Function in Dialysis Patients
17
The recurrent factor is this: Traces of eroticization of the relationship with the dialysis partner appear in the imagination of dialysis patients, even when the dialysis partner is not the institutional sexual partner, i.e. the spouse. Α young dialysis patient whose dialysis partner is his sister, with whom he says he has a `fantastic' relationship (`one of the few things that keeps me going'), and who feels that he has involved her in his suffering too much, recounted a dream with the following manifest content:
(He did not explicitly name his sister, but the context referred to her.) In the metaphor of the blood which boils uncontrollably and tends to overflow the set limits of the lid dangerously in the presence of and almost as an anguished offering to the partner, we feel that a glimpse can be seen of the signifier of the fear of involving the sister too much; a splinter of an ancient, archaic expectation in which the desire for intimacy and confidence and all that takes place in the emotional and symbolic atmosphere of the dialysis rite reawakens deep-rooted memories and perceptions of early stages in the development of the children of man, in which the desire for belonging, merger, intimacy and the desire to be reclaimed and healed combines and is mingled with a vague, general, indistinct, erotic perception of fusion. We wish to draw particular attention to this subject from the psychoanalytical standpoint; this endogamic tendency characterizes the emotional and sexual universe of the dialysis patient who, withdrawing his/her emotional and sexual investment in the outside world, tends to concentrate it within the family, bringing into the family the intense erotic expectations normally experienced outside it. However, the approach which seems to us best to characterize in metaphorical terms the general atmosphere in which the dialysis patient's sexual fantasies and acts are experienced is to consider this area as being characterized by the values and intentions of an eternal convalescence; the eloquent, dramatic stage of the worsening illness has been followed by the sort of semirecovery represented by the commencement of dialysis which
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
. . I was doing my dialysis, at home, and it was going better than usual ... I forgot a klemer on the tube. There was a sort of filter, a huge transparent bowl with blood in it. I noticed the mistake with the open klemer, and the blood started boiling up in the bowl. There was someone there, I don't know who. I turned to someone in mounting panic. As soon as I woke up I thought of my sister. The blood boiled and seeped out from under the lid ... I have dreams that aren't easy to tell, sexual dreams, often, abnormal things that I can't accept ... I dream of making love to a member of my family, and I can't accept it ...'.
18
opens up a possible future inhabited by disquieting questions and great hopes; in the meantime it is equipped as the ecosystem to which the patient belongs, which needs to be protected and supervised daily in accordance with rituals and rhythms whose beneficial properties the patient learns to use. This convalescence continues for an indefinite period, threatened by the risk of relapse into an acute state of illness or sudden worsening, but also inspired by the hope of further improvement; however, this does not appear to be a state patients resign themselves to, but a residual benefit to be protected and which they would be well advised to learn to enjoy. It is this emotional philosophy which we feel provides the framework for the dialysis patient's sex life. Like many other experiences associated with biological impulses such as eating, drinking and running, sexual intercourse is placed under the aegis of dialysis. However, making love obeys the dictates of a mechanism which to some extent is more sensitive and delicate, and is certainly more touchy than those governing hunger or thirst; it therefore withdraws to a distance more readily, waiting to see how the situation develops, and pushing forward other needs, such as the supreme need to organize one's survival as well as possible. It is just this swallowing up of the adult emotional investment (in the working, social and erotic life) by situations which in psychoanalytical terms could be described as more narcissistic in the etymological sense of the word, i.e. focusing on the self-preservation instinct, which organizes the dialysis patient's sex life. This may be one of the reasons why the swallowing up into this narcissistic vortex of the backward genital investments towards the family, the self and the preservation instinct causes the dialysis patient, in particular those undergoing home dialysis, to rediscover the natural maternal values ruling the family of which the dialysis partner is a member, and within which a very primitive symbiotic situation is recreated. Within this emotional philosophy promoted by the experience of dialysis, it appears that endogamy, i.e. the eroticization of the dialysis partner, becomes a manifestation of the need for profound unions alternative to the emotional investment in what lies outside the family, which is synonymous with growth but which, in the experience of dialysis, becomes the signifier of a dangerous, overexposed situation. Α sort of dilemma therefore arises in the emotional universe of the patient between remaining inside, belonging, being looked after, return and symbiosis with the family (an apparatus which purifies and heals) and tackling the outside world, imprudence, adventure and distance.
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
Pietropolli Charmet
Sexual Function in Dialysis Patients
19
Within this sort of narcissistic stronghold which often takes a rather polemical, grudging approach to the outside world, and which ultrainvests the family environment with working energy, the Eros seems to move from channels which allow its sexual expression and satisfaction towards other sensory channels and other symbolic areas. The patient apparently regresses, but in fact, in our opinion, seems to rediscover a new symbolic dimension on the one hand and a newly natural strength on the other. In the interviews, some patients spoke of bright, luminous, extremely vivid sensory experiences. In the context of an interview designed to obtain information about their sex lives, they talked of new experiences of pleasure not associated with genital sexuality. These are very private, deep experiences involving the rediscovery of the beauty and harmony of nature and sudden contact with other natural aspects which amaze them. The following are the words of man who has been undergoing hemodialysis for over 15 years, and who is quite elderly, talking about this experience:
These experiences are important in clarifying the relationship this man has with a harmonious, benevolent Mother Nature; he retains a relationship with her which has a pre-symbolic, sensory character. These experiences indicate the possibility that in the extreme conditions under which the human experiences of the dialysis patient take place, old, obsolete sensory channels are opened up to restore contact with nature, the instinct and the primitive Eros, allowing the fruition of deeply pleasurable experiences. While I was processing the data obtained in this survey, I was reminded of what appears quite clearly as a basic query in other life-threatening situations — all those situations in which the survival is strongly threatened and the patient is now in an intermediate stage, but will not come out of ít by being cured, only by rearranging and resymbolizing his/her life within a new emotional frame of reference. I was reminded of the basic question involved in organizing life in other situations which are partly comparable to this one, which we identified
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
. . I no longer feel free to go out. I love sailing and I used to go out with my boat, on the sea, sometimes with my daughter. Now I can't ... I can only make short trips .. . there's no more feeling of adventure. I've become less active, more contemplative ... I have a great relationship with nature even now that life can't offer me a lot. I'm happy with it anyway, although it's less than I had before ... but it's a more intense enthusiasm, I appreciate it more. For example, I went to my seaside home last week and my son had cut the lawn — I really enjoyed the smell of newly mown grass, and I thought to myself, "well, 20 years ago I wouldn't have noticed it, yet it's fantastic"; later it rained, and the woodland smell came down from the mountains ...'.
Pietropolli Charmet
20
. . I went to Paris, to a hotel where (according to the dream, and I think in real life too) I had been with my husband in the early days. The hotel was quite an expensive one. I went out for a walk and to meet some other people ... after I had been with the others for a while, I realized I hadn't made a note of the name and address of the hotel. I was rather dismayed, because I'd left my dialysis bags at the hotel and it was getting close to changeover time. Later I found a piece of paper in my pocket with an abbreviation and a telephone number which must have been the hotel's. I showed it to the others joyfully, and with a feeling of revenge ... In the meantime I'd been distracted by other things — piles of prawns and clams waiting to be cooked, but which looked as though they'd gone bad, in a liquid which looked like something produced by their deterioration. I was getting distracted from the rest of the group, who had sat down to eat in the meantime. Someone asked me to join them, but I maybe needed to have a wee-wee first. It wasn't clear, anyway, I hesitated. Then from the staircase of a large terrace two elegant little old ladies appeared, looking for someone. I went to call this "someone", an elderly man, not very big either. He followed me to meet the old ladies, who (I now noticed) were carrying flowers. They saw each other from far off and ran towards each other — as they ran he turned into a fox terrier puppy and the two old ladies got smaller, looking almost like two kittens. The fox terrier caught up with them and started kissing one of them frantically and tenderly ...'.
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during research into the rehabilitation of patients who had suffered heart attacks — after the heart attack life continues, but does love? This same question can be posed in the context of the life-style following on after a mastectomy necessitated by breast cancer — life goes on, but does love? In these extreme situations, the survival of the self seems to become the strategic target which coordinates the entire emotional life and the emotional investment policy. We consider that the survival of the self is best guaranteed by general mobilization of the parental rather than the erotic skills. Basically, it is quite natural that if the experience of the dialysis patient can be described as an eternal convalescence, what organizes the entire emotional sphere is the attempt to generate magic parental capacities in the world around, the only ones which in our experience of growing up have proved able to cope with states of suffering and enigmas which the individual alone is unable to tackle and solve. Does not the Eros between man and woman basically contain a secret generative tension? Yet what generative capacity can exist under such extreme circumstances? To paraphrase the words of one respondent, in the eyes of the dialysis patient eroticism appears in the form of peacetime soppiness; in wartime one thinks of saving one's skin, and when in pain cries `Mother', not `Mary'. I will conclude by recounting images from the dream of a 50-year-old woman patient who has been undergoing peritoneal dialysis for some 4 years. The manifest content of the dream is as follows:
21
I do not wish to suggest a detailed, orthodox psychoanalytical interpretation of this dream. I merely propose to suggest the almost transparent meaning of these images, using them as an explicit metaphor for the way the emotional relationship between the dialysis patient and the dialysis bags tends to replace the meeting between man and woman as if in a singular metamorphosis. However, we will begin with the nightmare. The trip to Paris is associated by the thoughts in the dream with a second honeymoon, a pilgrimage to a place in which the rite of conjugal love was first celebrated. The content of the dream therefore seems to be a comparison between the sexuality of the past, that of the early years of marriage, and that of the present, at a time of peritoneal dialysis. What counts now, during the dream return to Paris, is the almost phobic fear of losing the reassuring contact with the dialysis bags containing everything needed for dialytic purification. The bags are in the hotel which symbolizes the hospital; the H sign of the hospital is also the abbreviation of the hotel marked on the sheet of paper. Although the dreamer would like to do the same as her friends who venture into the involving experience of the eroticized life of Paris, she is afraid of losing the relationship, signs and way which can save her in case of need — she is afraid of going too far away. In the meantime, however, she goes on her way with the healthy group of people who still enjoy the supreme gift of health, and she thinks of the difficulties she may come up against in her present situation in rapidly getting hold of the things that guarantee her survival, namely the bags which are in a hotel/ hospital from which she has strayed too far. In the meantime, prawns and clams which have gone bad appear in the dream, signifying children, sex organs, internal organs protected by a shell, i.e. kidneys which no longer work properly and are immersed in a liquid which seems to be the product of their deterioration. This situation opens into the next image, where the others sit down to eat (go to bed), but the dreamer first has to go to the toilet (perform her dialysis) and is unable to share the experience of eating together with the others, being obliged to perform a more secret ritual which, on the basis of the vocabulary she used in recounting the dream, takes on the semantic value of a physiological ritual of childish cleansing. Against this background, where the prevalent emotional concerns seems to be maintaining efficient, controlled contact with the dialysis/bags/hispital/urinating, the two old ladies appear, looking for their partner. The dreamer imagines that she can act as a messenger of love and bring the old gentleman into contact with the two ladies carrying flowers, which
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Sexual Function in Dialysis Patients
22
maybe express the feminine desire to make a loving offer to the partner of the past. The dreamer helps the act of mating; however, as it comes into the story, leaving the realm of fantasy and becoming a reality, it undergoes a singular metamorphosis and the old gentleman, the former sexual partner, turns into an affectionate fox terrier puppy and the two ladies turn into delightful beckoning kittens. The dreamer transforms elderly people and their desire into signifiers of children, where the meeting loses its sexual content and becomes the tender, joyful, intelligent and now reconciled meeting between cat and dog, man and woman, happy to find one another even without their previous erotic passion which has now paled into peaceful co-existence. We feel that this dream summarizes the central themes marking the perimeter within which the dialysis patient's unique personal history lies. One side of this perimeter consists of the hotel/hospital/bag which the patient cannot stray too far from, while another is represented by the prawns and clams which had gone bad, internal organs which are no longer good. Another side is marked by the experience of having to distance oneself from other people's rituals to perform one's own personal dialysis ritual. The last side is that of the desexualization of the meetings in Paris between man and woman and their transformation into the affectionate, reconciled confidences and intimacy of animals which have become pets. To conclude our analysis, we feel that we can delineate a working hypothesis for the continuance of a research project which cannot be limited to the analysis of a few cases; those already examined seem to open up some prospects for reflection. Our hypothesis is as follows: the condition of dialysis, like similar extreme conditions and perhaps more so, destroys the representation of the bodily self which the patient has constructed. It destroys it because it forces the person to restructure his/her ecosystem (in terms of diet and performance), thereby significantly altering the pattern of sexual activity. The patient therefore has to re-symbolize his/her self. In particular, in the case of sexuality, the patient digs up archaic forms of the Eros to recover the significance of ancient experiences associated with the closeness of the mother's body and the prevalence of tenderness and reassuring intimacy. This does not mean denying nostalgia for a genital activity which has been impoverished and in some cases disappears, but is designed to recover new areas in the mind through the most exclusive human function — that of symbolization.
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Pietropolli Charmet
Sexual Function in Dialysis Patients
23
References
G. Pietropolli Charmet, MD, Institute of Psychology, University of Milan, Via Larga 19, I-20122 Milano (Italy)
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Gastaldi, S.: Esperienze di formazione all'Istituto dei Tumori di Milano. Atti del Convegno Un'Esperienza per la Qualificazione degli Operatori dei Servizi SocioSanitari USL N 66 Milano, 1982. Fornarí, F.: I fondamenti di una teoria psicoanalitica del linguaggio (Boringhierí, Torino 1979). Fornarí, F.; Frontorí, L.; Riva Crugnola, C.: Psicoanalisi in ospedale (Raffaello Cortina, Milano 1988). Greenberg, J.R.; Mitchell, S.A.: Object relations in psychoanalytic theory (Harvard University Press, Cambridge 1983). Pietropolli Charmet, G.: Un'esperienza per la qualificazione degli operatori dei servizi socio-sanitari; in Atti del Convegno Della USL N. 66, 24 Maggio 1982, con Istituto di Psicologia della Facοltá di Lettere e Filosofia (Universitá Statale di Milano), Federazione Sanitá Cgil, Cisl, Uil, Regione Lombardia. Pietropolli Charmet, G.; Leonelli Langer, L.: Hospital psychological consultation in voluntary abortion; in Atti del I Congresso di PPO, Atene, 1983. Pietropolli Charmet, G.: I codici affettivi prevalenti nella cultura psichiatrica attuale; in Il tempo del disagio (Rosenberg & Sellier, Torino 1 984a). Pietropolli Charmet, G.: Nuove professionalitá in ospedale: lo psicologo clinico; in Devianza ed emarginazione, III, 1 (II), Giugno, 1984b. Pietropolli Charmet, G.; Di Blasi, Μ.; Jahsen, C.: Tempo, stati psicotici, strutture intermedie; in Le psicoterapie nei servizi psichiatrici (Angeli, Milano 1985). Pietropolli Charmet, G.; Tonelli, G.: Modelli culturali in psichiatria (Unicopli, Milano 1985). Pietropolli Charmet, G.; Riva, E.: Formazione e gruppi di lavoro (Cortina, Milano 1986). Pietropolli Charmet, G.: (A cura di) La democrazia degli affetti. Formazione psicologica in ospedale (Cortina, Milano 1987). Pozzi, G.: Un nuovo modello istituzionale per la riabilitazione degli stomizzati. Atti del Congresso Internazionale di Stomoterapia, Ravenna USL 35, 1986. Riva Crugnola, C.: Simbolo e conoscenza (Cortina, Milano 1985).
Sexual Function in Dialysis Patients Psychological Aspects G. Pietropolli Charmet University of Milan, San Carlo Borromeo Hospital, Milano, Italy
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
With a view to providing data of some interest for this seminar, we have processed the initial results of one section of a more extensive research project we are conducting on the symbolic, affective and relational universe of the dialysis patient. We have put together a sample of men and women undergoing dialysis, obtaining information in interviews and clinical discussions. We considered that it would also be useful to obtain details of dreams. Our research group operates on the basis of a psychoanalytical theory, and the material we worked on therefore consists of the associations of our respondents and their dreams. We have processed the data in accordance with the symbol interpretation criteria used in modern communication analysis, with special reference to the theory of affective codes devised by Italian psychoanalyst Franco Fornari. Our sample of patients makes no pretence at being statistically significant; it is a reasoned sample, selected in accordance with qualitative research criteria. Our aim was to collect some prevalent symbolizations, i.e. some trends in the process in which the dialysis patient's way of thinking, feeling and loving develops. On the basis of the data processed, the first consideration of a very general nature is that the experience of survival through dialysis involves at least a partial loss of sexual interest. The patients we interviewed said that their erotic relationships with their sexual partners or potential partners are considerably diluted, and tend in time to dissolve. This does not necessarily mean that their sex life disappears; the motivation for meetings, actual practice and sexual intercourse wanes and fades away. What could be called occasional sexual intercourse remains, however, within a stable, established emotional relationship.
16
When considering the dominant emotion which is developed in relation to this situation, regret for the loss of a deep personal sexual motivation and the loss of spontaneous sexual desire seems to be slight; the search for pleasure or the path followed by the deep-rooted desire of the dialysis patient changes, and it is this that we have endeavored to identify. This reduction in the quantity and quality of the sex life which is actually triggered by desire is a process of a general nature in the patient's life which eventually leads the patient to invest all his/her emotional expectations in the family to which he/she belongs, bringing to it desires and fantasies which, when life is lived under less extreme conditions, are normally directed outside the family. We will now consider the quality of feelings and the intention of the sexual desire in the patient's sex life (when it exists). As sexual desire as such rarely makes a spontaneous appearance in the patient's mind and body with the force and passion of the past, as the sexual inspiration is very faint, what promotes sexual initiative towards the partner seems to be a motivational spur of a different kind. We have identified two which seem to represent the organizers of the dialysis patient's sexual initiative. The first has the result that the sexual partner is seen in emotional terms which psychoanalytically speaking could be described as depressive. In this case, the patient feels that he/she has disappointed, neglected, even `sucked the blood' of the sexual partner who is relegated to a sort of emotional and sexual backwater; the sexual initiative is a way of making amends for the neglect and oblivion to which the partner has been subjected. The `starter motor' of the sexual initiative is not desire, but a sort of odd sense of guilt for not having loved enough, for having allowed the partner's erotic expectations to age and wither. The other dominant perception, which we feel is more of a background in characterizing the patient's sexual initiative, configures the sexual partner as the repository of an avid, heedless, intrusive attitude to the patient. This is generally the perception of a female dialysis patient; they describe their partners' claims in frankly persecutional terms because of the discomfort, almost amounting to suffering, and the generally icy atmosphere in which the erotic experience takes place under these circumstances. From the psychoanalytical standpoint we feel it interesting to emphasize a factor which recurs with some frequency in the imagination of dialysis patients, in particular those undergoing home dialysis, and which was identified on the basis of interviews and the interpretation of dreams recounted by respondents.
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
Pietropolli Charmet
Sexual Function in Dialysis Patients
17
The recurrent factor is this: Traces of eroticization of the relationship with the dialysis partner appear in the imagination of dialysis patients, even when the dialysis partner is not the institutional sexual partner, i.e. the spouse. Α young dialysis patient whose dialysis partner is his sister, with whom he says he has a `fantastic' relationship (`one of the few things that keeps me going'), and who feels that he has involved her in his suffering too much, recounted a dream with the following manifest content:
(He did not explicitly name his sister, but the context referred to her.) In the metaphor of the blood which boils uncontrollably and tends to overflow the set limits of the lid dangerously in the presence of and almost as an anguished offering to the partner, we feel that a glimpse can be seen of the signifier of the fear of involving the sister too much; a splinter of an ancient, archaic expectation in which the desire for intimacy and confidence and all that takes place in the emotional and symbolic atmosphere of the dialysis rite reawakens deep-rooted memories and perceptions of early stages in the development of the children of man, in which the desire for belonging, merger, intimacy and the desire to be reclaimed and healed combines and is mingled with a vague, general, indistinct, erotic perception of fusion. We wish to draw particular attention to this subject from the psychoanalytical standpoint; this endogamic tendency characterizes the emotional and sexual universe of the dialysis patient who, withdrawing his/her emotional and sexual investment in the outside world, tends to concentrate it within the family, bringing into the family the intense erotic expectations normally experienced outside it. However, the approach which seems to us best to characterize in metaphorical terms the general atmosphere in which the dialysis patient's sexual fantasies and acts are experienced is to consider this area as being characterized by the values and intentions of an eternal convalescence; the eloquent, dramatic stage of the worsening illness has been followed by the sort of semirecovery represented by the commencement of dialysis which
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
. . I was doing my dialysis, at home, and it was going better than usual ... I forgot a klemer on the tube. There was a sort of filter, a huge transparent bowl with blood in it. I noticed the mistake with the open klemer, and the blood started boiling up in the bowl. There was someone there, I don't know who. I turned to someone in mounting panic. As soon as I woke up I thought of my sister. The blood boiled and seeped out from under the lid ... I have dreams that aren't easy to tell, sexual dreams, often, abnormal things that I can't accept ... I dream of making love to a member of my family, and I can't accept it ...'.
18
opens up a possible future inhabited by disquieting questions and great hopes; in the meantime it is equipped as the ecosystem to which the patient belongs, which needs to be protected and supervised daily in accordance with rituals and rhythms whose beneficial properties the patient learns to use. This convalescence continues for an indefinite period, threatened by the risk of relapse into an acute state of illness or sudden worsening, but also inspired by the hope of further improvement; however, this does not appear to be a state patients resign themselves to, but a residual benefit to be protected and which they would be well advised to learn to enjoy. It is this emotional philosophy which we feel provides the framework for the dialysis patient's sex life. Like many other experiences associated with biological impulses such as eating, drinking and running, sexual intercourse is placed under the aegis of dialysis. However, making love obeys the dictates of a mechanism which to some extent is more sensitive and delicate, and is certainly more touchy than those governing hunger or thirst; it therefore withdraws to a distance more readily, waiting to see how the situation develops, and pushing forward other needs, such as the supreme need to organize one's survival as well as possible. It is just this swallowing up of the adult emotional investment (in the working, social and erotic life) by situations which in psychoanalytical terms could be described as more narcissistic in the etymological sense of the word, i.e. focusing on the self-preservation instinct, which organizes the dialysis patient's sex life. This may be one of the reasons why the swallowing up into this narcissistic vortex of the backward genital investments towards the family, the self and the preservation instinct causes the dialysis patient, in particular those undergoing home dialysis, to rediscover the natural maternal values ruling the family of which the dialysis partner is a member, and within which a very primitive symbiotic situation is recreated. Within this emotional philosophy promoted by the experience of dialysis, it appears that endogamy, i.e. the eroticization of the dialysis partner, becomes a manifestation of the need for profound unions alternative to the emotional investment in what lies outside the family, which is synonymous with growth but which, in the experience of dialysis, becomes the signifier of a dangerous, overexposed situation. Α sort of dilemma therefore arises in the emotional universe of the patient between remaining inside, belonging, being looked after, return and symbiosis with the family (an apparatus which purifies and heals) and tackling the outside world, imprudence, adventure and distance.
Downloaded by: Université de Paris 193.51.85.197 - 2/14/2020 8:00:46 AM
Pietropolli Charmet
Sexual Function in Dialysis Patients
19
Within this sort of narcissistic stronghold which often takes a rather polemical, grudging approach to the outside world, and which ultrainvests the family environment with working energy, the Eros seems to move from channels which allow its sexual expression and satisfaction towards other sensory channels and other symbolic areas. The patient apparently regresses, but in fact, in our opinion, seems to rediscover a new symbolic dimension on the one hand and a newly natural strength on the other. In the interviews, some patients spoke of bright, luminous, extremely vivid sensory experiences. In the context of an interview designed to obtain information about their sex lives, they talked of new experiences of pleasure not associated with genital sexuality. These are very private, deep experiences involving the rediscovery of the beauty and harmony of nature and sudden contact with other natural aspects which amaze them. The following are the words of man who has been undergoing hemodialysis for over 15 years, and who is quite elderly, talking about this experience:
These experiences are important in clarifying the relationship this man has with a harmonious, benevolent Mother Nature; he retains a relationship with her which has a pre-symbolic, sensory character. These experiences indicate the possibility that in the extreme conditions under which the human experiences of the dialysis patient take place, old, obsolete sensory channels are opened up to restore contact with nature, the instinct and the primitive Eros, allowing the fruition of deeply pleasurable experiences. While I was processing the data obtained in this survey, I was reminded of what appears quite clearly as a basic query in other life-threatening situations — all those situations in which the survival is strongly threatened and the patient is now in an intermediate stage, but will not come out of ít by being cured, only by rearranging and resymbolizing his/her life within a new emotional frame of reference. I was reminded of the basic question involved in organizing life in other situations which are partly comparable to this one, which we identified
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. . I no longer feel free to go out. I love sailing and I used to go out with my boat, on the sea, sometimes with my daughter. Now I can't ... I can only make short trips .. . there's no more feeling of adventure. I've become less active, more contemplative ... I have a great relationship with nature even now that life can't offer me a lot. I'm happy with it anyway, although it's less than I had before ... but it's a more intense enthusiasm, I appreciate it more. For example, I went to my seaside home last week and my son had cut the lawn — I really enjoyed the smell of newly mown grass, and I thought to myself, "well, 20 years ago I wouldn't have noticed it, yet it's fantastic"; later it rained, and the woodland smell came down from the mountains ...'.
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. . I went to Paris, to a hotel where (according to the dream, and I think in real life too) I had been with my husband in the early days. The hotel was quite an expensive one. I went out for a walk and to meet some other people ... after I had been with the others for a while, I realized I hadn't made a note of the name and address of the hotel. I was rather dismayed, because I'd left my dialysis bags at the hotel and it was getting close to changeover time. Later I found a piece of paper in my pocket with an abbreviation and a telephone number which must have been the hotel's. I showed it to the others joyfully, and with a feeling of revenge ... In the meantime I'd been distracted by other things — piles of prawns and clams waiting to be cooked, but which looked as though they'd gone bad, in a liquid which looked like something produced by their deterioration. I was getting distracted from the rest of the group, who had sat down to eat in the meantime. Someone asked me to join them, but I maybe needed to have a wee-wee first. It wasn't clear, anyway, I hesitated. Then from the staircase of a large terrace two elegant little old ladies appeared, looking for someone. I went to call this "someone", an elderly man, not very big either. He followed me to meet the old ladies, who (I now noticed) were carrying flowers. They saw each other from far off and ran towards each other — as they ran he turned into a fox terrier puppy and the two old ladies got smaller, looking almost like two kittens. The fox terrier caught up with them and started kissing one of them frantically and tenderly ...'.
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during research into the rehabilitation of patients who had suffered heart attacks — after the heart attack life continues, but does love? This same question can be posed in the context of the life-style following on after a mastectomy necessitated by breast cancer — life goes on, but does love? In these extreme situations, the survival of the self seems to become the strategic target which coordinates the entire emotional life and the emotional investment policy. We consider that the survival of the self is best guaranteed by general mobilization of the parental rather than the erotic skills. Basically, it is quite natural that if the experience of the dialysis patient can be described as an eternal convalescence, what organizes the entire emotional sphere is the attempt to generate magic parental capacities in the world around, the only ones which in our experience of growing up have proved able to cope with states of suffering and enigmas which the individual alone is unable to tackle and solve. Does not the Eros between man and woman basically contain a secret generative tension? Yet what generative capacity can exist under such extreme circumstances? To paraphrase the words of one respondent, in the eyes of the dialysis patient eroticism appears in the form of peacetime soppiness; in wartime one thinks of saving one's skin, and when in pain cries `Mother', not `Mary'. I will conclude by recounting images from the dream of a 50-year-old woman patient who has been undergoing peritoneal dialysis for some 4 years. The manifest content of the dream is as follows:
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I do not wish to suggest a detailed, orthodox psychoanalytical interpretation of this dream. I merely propose to suggest the almost transparent meaning of these images, using them as an explicit metaphor for the way the emotional relationship between the dialysis patient and the dialysis bags tends to replace the meeting between man and woman as if in a singular metamorphosis. However, we will begin with the nightmare. The trip to Paris is associated by the thoughts in the dream with a second honeymoon, a pilgrimage to a place in which the rite of conjugal love was first celebrated. The content of the dream therefore seems to be a comparison between the sexuality of the past, that of the early years of marriage, and that of the present, at a time of peritoneal dialysis. What counts now, during the dream return to Paris, is the almost phobic fear of losing the reassuring contact with the dialysis bags containing everything needed for dialytic purification. The bags are in the hotel which symbolizes the hospital; the H sign of the hospital is also the abbreviation of the hotel marked on the sheet of paper. Although the dreamer would like to do the same as her friends who venture into the involving experience of the eroticized life of Paris, she is afraid of losing the relationship, signs and way which can save her in case of need — she is afraid of going too far away. In the meantime, however, she goes on her way with the healthy group of people who still enjoy the supreme gift of health, and she thinks of the difficulties she may come up against in her present situation in rapidly getting hold of the things that guarantee her survival, namely the bags which are in a hotel/ hospital from which she has strayed too far. In the meantime, prawns and clams which have gone bad appear in the dream, signifying children, sex organs, internal organs protected by a shell, i.e. kidneys which no longer work properly and are immersed in a liquid which seems to be the product of their deterioration. This situation opens into the next image, where the others sit down to eat (go to bed), but the dreamer first has to go to the toilet (perform her dialysis) and is unable to share the experience of eating together with the others, being obliged to perform a more secret ritual which, on the basis of the vocabulary she used in recounting the dream, takes on the semantic value of a physiological ritual of childish cleansing. Against this background, where the prevalent emotional concerns seems to be maintaining efficient, controlled contact with the dialysis/bags/hispital/urinating, the two old ladies appear, looking for their partner. The dreamer imagines that she can act as a messenger of love and bring the old gentleman into contact with the two ladies carrying flowers, which
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Sexual Function in Dialysis Patients
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maybe express the feminine desire to make a loving offer to the partner of the past. The dreamer helps the act of mating; however, as it comes into the story, leaving the realm of fantasy and becoming a reality, it undergoes a singular metamorphosis and the old gentleman, the former sexual partner, turns into an affectionate fox terrier puppy and the two ladies turn into delightful beckoning kittens. The dreamer transforms elderly people and their desire into signifiers of children, where the meeting loses its sexual content and becomes the tender, joyful, intelligent and now reconciled meeting between cat and dog, man and woman, happy to find one another even without their previous erotic passion which has now paled into peaceful co-existence. We feel that this dream summarizes the central themes marking the perimeter within which the dialysis patient's unique personal history lies. One side of this perimeter consists of the hotel/hospital/bag which the patient cannot stray too far from, while another is represented by the prawns and clams which had gone bad, internal organs which are no longer good. Another side is marked by the experience of having to distance oneself from other people's rituals to perform one's own personal dialysis ritual. The last side is that of the desexualization of the meetings in Paris between man and woman and their transformation into the affectionate, reconciled confidences and intimacy of animals which have become pets. To conclude our analysis, we feel that we can delineate a working hypothesis for the continuance of a research project which cannot be limited to the analysis of a few cases; those already examined seem to open up some prospects for reflection. Our hypothesis is as follows: the condition of dialysis, like similar extreme conditions and perhaps more so, destroys the representation of the bodily self which the patient has constructed. It destroys it because it forces the person to restructure his/her ecosystem (in terms of diet and performance), thereby significantly altering the pattern of sexual activity. The patient therefore has to re-symbolize his/her self. In particular, in the case of sexuality, the patient digs up archaic forms of the Eros to recover the significance of ancient experiences associated with the closeness of the mother's body and the prevalence of tenderness and reassuring intimacy. This does not mean denying nostalgia for a genital activity which has been impoverished and in some cases disappears, but is designed to recover new areas in the mind through the most exclusive human function — that of symbolization.
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Pietropolli Charmet
Sexual Function in Dialysis Patients
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References
G. Pietropolli Charmet, MD, Institute of Psychology, University of Milan, Via Larga 19, I-20122 Milano (Italy)
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