Introduction

In psycho-analytic literature the fetish has been discussed exclusively as an auxiliary object or device in the service of heterosexual gratification, and as a defence against perversions proper, particularly homosexuality. Freud (1927) had derived the aetiology of fetishism from castration anxiety relating to the phallic phase. He had established the psychic contents of the fetish as denial of castration and had stated: 'The fetish is a substitute for the woman's (mother's) penis that the boy once believed in and does not want to give up.' By his emphasis on the singular importance of the mechanisms of denial (disavowal) and splitting in the ego's attempt to deal with the castration threat Freud (1927, 1938) had also established the beginnings of researches into ego pathology and its relation to perversions which have since enlarged extensively the aetiology of fetishism to include: (a) primary preoedipal relation to the (breast) mother (Lorand, 1930; Wulff, 1946; Buxbaum, 1960); (b) internal objects and early ego development (Payne, 1939; Gillespie, 1940, 1964; Hunter, 1954); (c) transitional object phenomena and primitive mental functioning (Winnicott, 1953; Lacan and Granoff, 1956; Fraser, 1963); (d) separation anxiety and the dread of abandonment (Bak, 1953; Weissman, 1957); (e) pathological body-ego development and threat of disintegration front disturbed mother-child relationship (Greenacre, 1953, 1960; Mittelmann, 1955); (f) bisexual primary identifications with the mother and the wish to bear a child (Kronengold and Sterba, 1936; Kestenberg, 1956; van der Leeuw, 1958; Socarides, 1960); (g) flight from incest (Romm, 1949); and (h) a defence against archaic anxiety affects which threaten the relation to reality with the accompanying dread of breakdown into psychotic states (Glover, 1932, 1933, 1949: Socarides, 1959; Katan, 1964).

In the literature, to my knowledge, there is only one case, reported by Bak (1953), where the patient indulged masturbatory practices with fetishistic homosexual fantasies relating to boys with buttocks of a certain shape and smoothness. I shall here present material from an overt male homosexual whose sexual interest and activities were exclusively centred round a fetishistic relation to the foreskins of uncircumcized youths. I shall try to detail the psychodynamics of this foreskin fetish and its defensive self- protective role in relation to the severe latent ego-pathology which derived from a grossly disturbed and intimate relation to his mother in his childhood.

¹Presented at a Scientific Meeting of the British Psycho-Analytical Society on 20 January 1965. Earlier versions were presented to the Philadelphia Association for Psychoanalysis and to the Los Angeles Psychoanalytic Society in April 1964. I am grateful to Dr John D. Sutherland, Dr Robert Waelder, and Dr Ralph Greenson for their helpful suggestions and criticisms.

Patient's Early History

The patient, a man of forty years of age, was one of four children. He had an elder brother and a sister two-and-a-half years younger. The parents had divorced when he was seven and the mother had married again soon afterwards; another boy followed within a year. Both marriages of the mother had been passionately, noisily and hysterically unhappy and she had intimately involved the patient in all her woes and emotional tantrums. She was a beautiful and ambitious girl who had miscalculated both times. According to her later insistent confessions to the patient, she had never loved her first husband whom she had reviled after divorce as a dirty man with nasty sexual habits. She had made out that the three sons (the youngest after the marriage) had all been her second husband's children, and to establish this fact she had their surname changed to his. The daughter she had conceived from another person. Her second husband was much older than she, and a rich and respectable citizen, who, however, lost all his wealth within a year of marrying tier. This had exaggerated her terror of poverty and disease and the children were made witnesses of her eloquent complaints and grievances against fate and the husbands. Instead of improving her economic status she had, in tact, to do with a humble existence now. She was, however, very devoted to the patient who idealized her as a person throughout his childhood, and he had a profound attachment of love and affection to her right up to his adolescence.

The patient, who had been circumsized at birth, had a curiously vivid memory of isolated events as well as of fantasies from his childhood which he produced schematically in the first week of his treatment. They mostly belonged to the period between three years and six years of age. Briefly they were:

Memories from age about 3:

1. Sitting on a china egg and imagining he had laid it; feeling very disappointed on discovering it was not real.

2. Being very interested in the penis of the geldings and imagining himself united to them via the urethra. (This fantasy stayed with him tilt 14 or 15 years of age and had become absorbed into his masturbation fantasies.)

3. Tasting milk direct from a cow's teats during milking time and disliking it intensely.

4. He has been told, though personally had no direct memory of it, that one day his parents found that all the rhubarb plants had been nibbled and bitten at the root. First they had thought it was the work of rats and then discovered it was he who had done it.

5. He and his brother began going to the parents' bed in the morning and he started to entertain a compulsive wish to suck his father's penis and wished his mother were not in the way. Once he tried tentatively and was rebuffed. When he was seven, and both the mother and her new husband had started to revile the father as a man of nasty habits, he had confessed to his mother that he had actually sucked his father's penis and she had readily believed it.

6. His only other memory of his father was of the latter's once by mistake piercing the patient's foot with a prong while digging potatoes in the garden. Apart from this he had only the vaguest notion of his father and thought he had been a kindly person.

7. He remembers playing with his new-born sister by the fire and setting the blanket on fire. He burnt his hand and the nanny soaked it with the baby's wet nappy. He was very attached to this nanny. She had been sacked when the mother re-married because she had told the children that it was not their father who had been a nasty man but their mother who had loose morals.

8. His most vivid memory of his mother was of being tickled by her throughout his childhood, especially on the soles of his feet, and being reduced to ravished helplessness.

Memories from age 5:

9. Of his mother's singing about fishermen lost at sea and his crying.

Memories from about 8 onwards:

10. Of his mother's bitter complaints against her first husband's sexual habits and her grievances against her second husband, with the patient always taking her side.

11. Of his mother's painfully congested breasts after her last child and his offering to suck them and being very relieved when refused.

12. Feeling terrified of his step-father on their first meeting and wishing he would go away and leave them alone. (He never got to know him well.)

13. Acute unhappiness when mother went on her honeymoon and starting sexual games with his brother and later threatening to tell on him.

14. It was also during this period (mother went away for six weeks) that he began noticing that his circumcized penis was different in shape from some boys'.

15. When he was eight, his parents moved to another country. From the period of his mother's divorce, remarriage, and move from home, started his obsession with foreskins. At first he had thought that the boys who had foreskins had an -abnormality. At 10 he wrote anonymously to the father of a boy in his class, advising him to have his son circumcized as his foreskin was abnormal. He was found out but not punished.

16. Of mother having an abortion done in the house, when he was ten, and seeing the nurse and pans full of blood and other material.

17. His first masturbation activities started while he was listening to the hysterical rows between his mother and step-father, at the age of 11.

18. When he was nineteen, his mother returned to the home country with her husband and left him at college. From this period his pruritis ani started and it persisted to the time of this analysis.

The patient presented these memories somewhat flamboyantly. Though he claimed to have a very good memory of his childhood, in fact there was very little else that he was able to produce during the first sixteen months of this analysis. Grecnacrc (1955) has pointed out the limited nature of the fantasies of the fetishist and this was true of this patient as well. He had almost no recall of any relationships to people other than his mother, brother, and father from his childhood and adolescence and all his masturbatory fantasying from puberty onwards had been almost adhesively centred on puberty this foreskin fetish. Later in the discussion of his ego pathology, it will be seen how much this blank affectless image of his own youth screened an extremely disturbed and crippled ego development as well as his incapacity for object relationships (cf. Khan, 1964a).

Psychodynamics of the Foreskin Fetish

The patient had sought treatment because of what he had ironically phrased 'a theoretical dislike of homosexuality'. By this he had meant that he did not wish to become or be regarded as 'a queer', meaning a socialized overt homosexual. He had described in a euphoric way his current existence as dedicated to sexual love and the sexual seduction of young men with foreskins. The search for foreskins on beautiful youthful male bodies had become his chief private and personal preoccupation, although he had successfully integrated it with a sophisticated professional life. He was an educated person, well-groomed, slick and elegant of speech, and fastidiously polished in his manners. I have described the sexual cravings and pursuits of this patient and their relation to his identity diffusion during the first sixteen months of his analysis in my paper 'Homosexuality and the Sexual Nursing of Self and Object' (1965). Here I shall detail the phenomenology of his specific sexual wish and activity: to find a youth with foreskin, perform fellatio on him, and then masturbate into the foreskin. Tile first phase of his analysis was filled up by euphoric and exhibitionistic accounts of his night-prowls in search of his accomplices. I have used the word 'accomplices' deliberately because he never once coerced a youth into sexual intimacy who had not been looking for a similar type of experience. There was also very little overtly nasty or sadistic or even unpleasant in his relation to his sexual object. The whole search for the suitable sexual object, the technique of seduction and the relation to the person of his sexual gratification were obsessionally ritualized. He had a compulsion to search for the foreskin object and if he failed, which was most infrequent. he was then reduced to masturbation. To this he always reacted with disgust, apathy, acute loss of self-esteem, and a sense of futility.

When the patient started the analysis his sexual activities had reached a crescendo of orgiastic excessiveness. He was fully aware of the dangers entailed (socially and legally) and early in his analysis had, as it were, reassured me by informing me that he had sufficient supply of poison should he find himself trapped, either through blackmail or police action. This type of splitting and denial was typical of him. Though he did his professional work efficiently and conscientiously he was concerned that he had lost all ambition and was living a day-to-day existence, without any real interest in his future.

The patient had had some sixteen months of analytic treatment in another country and it was during this previous analysis that he had acted out into real shared sexual experiences what had been till then merely obsessive private sexual ruminations with compulsive bouts of masturbation, which always left him disgusted with himself. Once he had started on his sexual adventures he had discovered his talent for such activities and when he came to me for treatment he could boast with some justice that there was not a youth he would wish to seduce who could resist him.

Though he had presented me with his stock of memories therc was little material in the sessions during the first phase that one could relate to his childhood experiences with any clinical cogency. Of course his manic, perfervid, and impassioned sexual pursuit of the youths, his lyrical accounts of their beauty and his greedy consumption of thcir semen could be all too easily translalted into patterns of childhood experiences with mother and father; but for me, at least, it was important not be seduced into this type of intclicctual analysis. I had also the fate of his first analysis as a good cautionary tale to guide my work. What had impressed me most from the start was that he had created for himself an ahistorical, as-if, screen identity in terms of his practices and pursuits relating to the foreskin fetishistic object. I have discussed theoretically this aspect of his behaviour in my paper, 'The Function of Intimacy and Acting Out in Perversions' (1964c). During the first sixteen months analytic work had been concentrated on weakening his manic defence (Winnicott, 1935) as it operated through the sexual practices and on enabling him to bear minor anxiety-states without taking recourse to automatic defensive manoeuvres of the erotic or obsessional kind (Khan, I964b). It was when the patient began to relax his hectic and furious pursuit of sexual adventures that it became possible to examine in detail the psychic and affective contents of his foreskin fetishism. At this stage he became regressed in mood, apathetic and depressive in affect, and more dependent on his relation to me and the analytic situation.

Greenacre (1953) in her definition of the fetish stressed that 'in some instances it is not only the possession of the object but a ritualistic use of it which is essential.' The ritual in relation to the person carrying the foreskin fetish was most revealing in the behaviour of this patient. Equally important was the affective inner climate which would compel him into night prowling and searching for the foreskin fetish. This affective inner climate was an amorphous and confused state of excitement, anxiety bordering on psychically indecipherable terror, and a dread collapse into total inertia and negativity (cf. Khan, 1964b).

I am now condensing details which were laboriously culled together clinically over a very long period of time. The fetishistic reverie and pursuit organized this larval confused agitated activity into an alert and active state of elation. Hence the fetishistic search for an object both organized the patient's amorphous affectivity and, by transforming the latter into an active modality of behaviour, rescued him from apathy and inertia. The nourishing aspect of this type of acting out into reality as flight from an endopsychic crisis that the patient could not deal with had a definite self-protective role. How abjectly helpless and paralysed he could be would occasionally become visible in the early phases when he had to stay indoors due to weather conditions and was reduced to masturbatory discharge activities.

Relationship to the Fetishistic Object

I shall differentiate the total fetishistic practices of this patient into two component parts: (a) his ego-relation to the fetishistic object, i.e. the uncircumsized youths with foreskins, and (b) the intimate physical sexual relation to the fetish proper, i.e. the foreskin itself. The patient himself was fully aware of this duality in his experience of, and relation to, the youth and his foreskin. He had always idealized and boasted about the nature of his concern for, and appreciation of, these youths as persons, whereas he regarded his activities with the foreskin as in the nature of 'childish and absurd games'. It became quite clear to me very early on in his analysis that the type of affects and defence mechanisms involved in his relation to the fetishistic object were quite different from those expressed in his sexual play with the foreskin. The meaning and psychic content of the latter became possible only through analysis of the first and enabling the patient to see himself in the fetishistic object.

I have mentioned the amorphous mood of agitation and latent excitement mixed with anxiety and apathy from which the patient would launch himself on his night-adventures. This form of acting out of the endopsychic crisis enabled his ego to use objectifying and anticipating functions (Hartmann, 1956). Instead of a phobic negativistic state of apathy the search for the fetishistic object would mobilize a selective range of ego-functions. This patient had been crippled throughout his latency. adolescence, and earlier youth by an intense form of apathy and phobic-paranoid withdrawal into himself, in which state his only eratitications were the immediate discharge activities of masturbation with their stereotyped fetishistic fantasies about foreskins. The search after, and the relationship to, the youths had enabled him to sense himself as a living, active, and effective human being. This had led gradually to an almost manic state of over-weening self-confidence and exaggerated self-regard. He now considered himself an omnipotent person, imperturbable and dedicated, to the rescuing and nursing of beautiful abandoned youths. He felt not only in touch with reality but also omnipotently munificent towards it. His argument was that he helped these young men to become more conscious of their innate dignity and superiority and so enhanced their self-esteem.

He selected a very special type of youth for his fetishistic object: he had to be uncircumcized and, in physique, strong and beautiful. In mood he should be listless, depressed, at a loose end and searching for sympathetic contact. The fetishistic object should not be an avowedly practising homosexual. i.e. the youth should not have accepted homosexual relationships as an ego-syntonic mode of sexual gratification. On the contrary, he should profess an overt dislike of such practices. If the patient felt that the youth was in himself already excited and looking for homosexual gratification he would drop him immediately. This mixture of confused unease, apathy, and negativity in the mood of the youth was important for the patient because this alone established (unconsciously) the identity of the youth as one like himself. This type of projective identification as the vehicle of object relationship I consider inherent in the ego-pathology of the pervert. Socarides (1959) has presented some very interesting clinical material exemplifying the role of projective identification in the pedophilic perversion in a male homosexual.²

² Anticipating my discussion of this patient's ego-pathology I would like to comment here that to designate this type of relationship as projective identification is somewhat of a misnomer. This type of ego interest and ego-cathexis of another person is more in the nature of a transitional state between relationship to the self and the relationship to the object, where neither the self nor the object are as yet fully differentiated as separate entities. I think we should use the concept of projective identification to designate an affective relationship where an internal object-representation is being displaced on to an external object and which further denies this ohjcct his own psychic arid existential reality. For my patient the existential realiy of the external object and its empathic perception were of vital importance.

Once he had established the significant and essential attributes in the object (the foreskin and the effective mood) he would then involve them in a verbal relationship. The youths he picked up were invariably 'lost souls' who felt abandoned, angry, suspicious, and ill-treated by life and worthy of a better deal. They were also as a rule grossly illiterate and quite often uncouth. The first task that he set himself in relation to the fetishistic object was to mellow the latter's mood and change it from negativity and suspiciousness into one of trust and cooperativeness. He always succeeded with remarkable ease and rapidity. That his successes were largely due to the simple fact that he had encountered the youths in an explicitly sexual situation and that sexual urgency goaded them into compliance he denied for a very long time. When eventually lie had to accept this fact it drove him to bleak despair and he gradually gave up the adventures. He always tried to convince them of two things: (a) that they were uniquely valuable persons, and (b) that they should treat themselves with dignity, reserve, and reverence. and expect this of others in relation to themselves as well. I need hardly say that this is precisely what the patient wanted for himself. In order to promote this quality of narcissistic self-regard in them he would volunteer to teach them the proper use of language, good manners, and other cultural attributes. He would also feed them and show them the necessity of body-hygiene. The youths were generally unkempt, dirty, and undernourished. He would also give them a little money. All this in a matter of hours. This would invariably lead to physical intimacy, but before I discuss that I will make a few comments on the meaning of this type of relation to the fetishistic object.

That the fetishistic object represented the aspects of the patient himself as a forlorn, deprived. and abandoned, as well as idealized and special, person is obvious. What was significant for the patient was that the acted-out relationship enabled him to make a restitution towards his own ego as well as to the external object. This was in marked contrast to his inner hopeless relation to himself and his equally futile relation to his mother throughout his childhood. Furthermore, in his role as a provider of comfort and nourishment he was identified with the primary good mother; active, omnipotent, and full of nurture (cf. van der Leeuw, 1958). It is my contention that this type of relation to the fetishistic object enabled this patient to resurrect a good early relation to his mother which had got lost through the vicissitudes of his family life from about four years of age onwards. Winnicott (1956) has postulated that behind the anti-social tendency there is a memory of a good (maternal) relationship that was present and got lost and the compulsion behind the anti-social tendency is to get back to this point and recover it. The patient in his relation to the fetishistic object was actively the good parent nursing the abandoned ideal child (youth).

The fetishistic object was also a whole person: intact and separate. The capacity to relate to him created the hope that not all was lost for ever. The illusional value of this type of relationship as a defence against a psychotic type of depression, apathy, and despair cannot be exaggerated. The relationship further established concretely the reality of the patient's identification with the good mother. He became and was the good parent (mother) in the transient expanse of such a relationship. It is possible to postulate here that in this type of patient the earliest relation to the mother has not been internalized. It is available only in terms of identifications and not as a stable internal representation of the good mother. Hence, when the patient was not operative in such an identificatory manner his sense of his self was one of bleak and morbid vacuity. The ego's incapacity to internalize the experience is also visible in the necessity to live through compulsive repetitions. The failure in his childhood development of a sustained good relation to the mother was dramatically repeated in the regressive breakdown in each encounter of the ego-cathexis in the fetishistic object as a person into the archaic and primitive sexual practices with the foreskin fetish.

Freud (1927) has stressed the mixture of affection for and hostility to the fetish. Aggresion towards the fetishistic object took a very culiar form in this patient, namely that of exciting deviously and indirectly the youths to a pitch of sexual tension in which thery would crave discharge-relief. This was done so subtly that it is difficult to recount it. Through his verbal pattern and narcissistic boosting of these youths' self-regard he managed to get them 'sexually over-heated' (to use the patient's phrase). To deny the operation of this factor in the early phase of the activities was important. In fact verbally a psychic resistance was built up in the youths against sexual intimacy. The aggression expressed took the form of gaining a complete mastery over the excited state of the youth. This excitement was not allowed to be personalized. It was engineered furtively and obliquely. The youths had to experience it in a dissociated way: responding to his ego-solicitations their narcissistic self-regard was heightened and they had to treat their excitement as a foreign body in their experience of self and treat it with casual cynicism. That they were used to sexual exploitation by their 'patrons' was adamantly denied, by him on purpose, and by them through collusion with his technique of relationship. So they invariably protested when he changed the direction of the episode from ego-support to sexual seduction. He knew precisely at what point their excitement had reached its peak. The role of sight and seeing was imperative here. He scanned every nuance of feeling and tension in their face and posture until he had worked up a 'colossal erection' in them. At this point his sense of achievement, triumph over, and mastery of the fetishistic object would be complete. He would now solicitously and compassionately offer to suck them and/or masturbate them. The excited helplessness of these uncouth, strong, aggressive youths had a specially pleasurable impact on the patient. Here a distinctly aggressive-sadistic element entered into his relation to them. He would secretly gloat over them: they were in his power. The more they got excited and frenzied with their sexual tension the more imperturbably quiet and gentle he became in his manner. He would often compel them to watch and see him masturbate them and make them ejaculate. He always swallowed the semen. The youth in the state of congested erection was both the mother and the excited self. At this point the inner status and psychic value of the object changed for him. He was the baby-person nourishing himself from the excited breast-penis of the youth (mother). He always had a guilty apprehension that this state of sexual excitement was not pleasurable for the youths. Here the identification of the youths with erection and the mother with painfully congested breast was complete. The youth with erection was also the phallic-breast mother. He had to hold tightly onto them whilc masturbating or sucking them. He could never cling hard enough and was for ever disappointed that this clinging grasping fervour in him meant so little to them. Here the disillusionment about the fetishistic object would already set in. He was also deeply aware of their humiliation and abject passive role in the masturbatory activity. Since he had first encouraged them to boast of their heterosexual inclinations and virility the situation of finding thernselves homosexually seduced was negated by the youths through a rough and cynical attitude towards the whole activity. This would mortily the patient. Never could he get them to acknowledge it as a good experience and this caused him both sorrow and pain. On the other hand, whenever someone did become excitedly eager and involved in the masturbatory experience he would lose interest and become frightened and withdrawn. The dread of the excited and exciting object was intense in him. The excited state in the fetishistic object had to be an encapsulated and localized one and under his control (cf. A. Freud, 1952).

After the youth had ejaculated, the relation to the fetish itself would come into full operation, although this is not strictly accurate, because the relation to the foreskin was biphasic: as a property of the erect penis and as a sac into which he masturbated. The total fetishistic event can be differentiated into three stages: (i) ego-relation to the fetishistic object as a person, (ii) sexual passive oral and manual relation to the erect penis and the foreskin, and (iii) active intrusive ejaculatory relation to the foreskin as a receptacle.

Before examining the psychic contents of the foreskin fetish proper I would like to emphasize the importance for this patient of the relation to the fetishistic object. In heterosexual fetishism the fetish functions as a reassurance against the (castration) anxieties relating to the female sexual object and sexual organs. In my patient the ego-relation to the homosexual fetishistic object operated as a reassurance against the archaic and regressive nature of the relation to the fetish itself. Gradually it became quite clear to the patient and me that he had sought treatment because of the inner threat to his ego and personality from the chaotic and archaic feelings and excitements of the foreskin fetish practices. During the first year and more of his analysis, his idealized and ecstatic pursuit of the fetishistic objects screened his dread of what was happening in the sexual practices themselves. He tended breezily to slur over them and described his frenzied sexual activities as 'cure through exhaustion'. The elation and greed experienced in relation to the foreskin fetish was truly frightening for him. His dreams in the earlier stages of analysis were barely cloaked primitive wish-fulfilment of the wish to suck the penis with the foreskin and swallow the semen. That he never experienced any real gratification was hidden from himself and vigorously denied in the narratives of his sexual exploits.

Psychodynamics of the Foreskin Fetish

I shall first schematically detail the meaning of the foreskin-penis in the state of erection and the patient's relation to it. He attributed a very special magical significance to the foreskin-penis in such a state. To him it represented the ideal breast-penis from thc first oral stage. It filled him with a sense of awe, fascination and excruciating excitement. By the timu he had brought the foreskin-penis into this stage of congested aliveness he felt it to be his 'creation' and treated it as such. Sight, touch, and smell played a significant part in his relation to it. He could never fully digest the pleasurable possibilities of the situation. He wanted to fuse and merge with it. It was nearer to a hallucinatory imago than a perception of a separate organ on another person or as a symbolic vehicle of relationship. Lacan and Granoff (1956) in their discussion of the role of the symbolic, the imaginary, and the real in fetishism have discussed this point in an intriguing manner. This regressive mode of relationship to the foreskin-penis fetish involved the breakdown of symbolic and secondary process mental activity. The patient felt he had created this magical object and through visual and manual touch and oral incorporation became it. This meant to him refinding and recreating concretely the original unity with the omnipotent nourishing breast-mother. Nunberg (1947) in his study 'Circumcision and Problems of Bisexuality' has established the fact that circumcision can mean loss of mother and has further detailed the meaning of the foreskin as symbolic of vagina, rectum, and femininity. The wish to suck father's penis has arisen in this patient following his younger sister's birth. He had always felt his own circumcized state a deficient, inadequate, and gender identity (cf. Greenson, 1964; Stoller, 1964). The fusion with the foreskin-penis re-established the lost omnipotent unity between the infantile pleasure-ego and the breast-penis-mother. It also served the function of denying the later traumatic separation from the mother through her marriage as well as negating his discovery that she was a castrated penis-less object. Nunberg (1947) has discussed his patient's fantasy that the female labia are a sort of foreskin that hide and protect the female penis. In my patient's fantasy and image this was true of the foreskin-penis. It was the ideal bisexual organ composed of the glans penis and foreskin-vagina united in inseparable (non-castrative) oneness. Hence his extreme delight and pleasure in it. The glans penis protected by the foreskin, which he could manipulate without injuring, meant also the primitive infant-self of the patient in the ideal protective nurturing ambience of the mother (foreskin), safely and pleasurably held by it.

The oral craving to fuse with the foreskin-penis and his idealization of a trance-like state of bliss that he experienced bear out the hypotheses offered by Greenacre (1953), Bak (1953) and Socarides (1960) that separation anxiety and the fear of abandonment are the primary anxiety affects in the fetishist. In this patient the repetitive recreation of this illusional oneness with the mother through the concrete and physical idiom of his oral and manual relation to the foreskin denied the separation from her and at the same time established a new transient event that was its own reality and negated the affects related to the (internal) maternal imago. This capacity to carry contradictory affects and motivations seems to make the fetishistic practices particularly effective in the ego's defensive manoevre against primitive and archaic emotional needs. The temporal element plays an important part here. The foreknowledge that the whole engineered event would last a short while and would be terminated by discharge (ejaculation) lessened the threat from the eruption of the very primitive body-needs and experiences with their traumatic genetic associations. The element of pleasure through gratification, the transience in time and the as-if make-believe of the whole fetishistic sexual game enabled the ego to split: thus if one part was involved another looked on with bemused objectivity. This dissociation defeated, however, the regressive motivation to fuse with breast-mother and in retrospect the patient had no internalized satisfactory image of the whole experience available.

Just as the attempts to boost the narcissistic self-regard of the fetishistic object (the youths) ended in compelling them to submit to the sexual orgy and thus experience humiliation, the oral-manual relation to the foreskin-penis with its exaggerated and idealised excitement and fervour also ended in a collapse (detumescence) of the omnipotent organ through ejaculation. The patient always felt sorry and apologetic towards the youths and had a sense of them as having suffered a pain and an injury. The unconscious intention cannibalistically to murder the loved object in an excited frenzy was clear here (cf. Payne, 1939).

Before I detail the third phase of the total fetishistic activity, i.e. the intrusive (aggressive) relation with the foreskin, I would like to single out the importance for this patient of swallowing the semen. He had a distinct notion of it as a very powerful substance with magical attributes and constituting the very essence of the vigour and beauty of the youths. It was both comic and pathetic the way he always tried to make them promise not to let their girl-friends perform fellatio on them. The rationalization he offered was (and this neatly betrayed the sadistic greedy and hostile intent in his behaviour) that girls would not respect them afterwards. The patient had at one time talked of his greedy compulsion to swallow semen as an addiction. An addiction it was too. It had the unconscious significance of incorporating a good substance which would neutralize his bad inner substances. We shall see later its magical curative value as a defence against hypochondriacal states. Glover (1932) has pointed out how transitory fetishistic phenomena appear when an alcoholic gives up his compulsive drinking. Here we see an addiction introduced into the very structure of a fetishistic practice. The infinite complexity of archaic body-processes, pregenital impulses, archaic primary process mentation and affect which the fetishist can tolerate in an unorganized state is a remarkable phenomenon that still needs proper explanation.

It was only after the youths had ejaculated and detumescence had set in that the third phase started and the patient moved from a passive-oral relation to an active intrusive phallic one. His wish was always to penetrate the sac of the foreskin with his penis. This was another variant of symbiotic fusion, but at a phallic level. And here he experienced his most painful mortifications because the youths never reciprocated his feelings. He wanted to be held tight and to be loved, and they were generally bored and aloof by this time. So his penis was never appraised as a good object and it ended in a mere discharge gratification for him, which left him sad and disconsolate. One important fantasy involved was the wish to enter the womb of the mother, to be engulfed and enveloped. The submergence of his penis into the foreskin was both a wish-fulfilment and a defence against it. There was a profound dread in him of his passive masochistic desire to submit to the phallic-omnipotent mother, as represented by the foreskin. This was borne out by his dreams in which claustrophobic anxiety played a prominent part and he felt trapped or asphyxiated.

His ejaculation brought the fetishistic activities to an end in a dismal bleak way because he never experienced pleasure in his orgasm and had a sense of disgust about his own semen. The termination of the excited events in this meagre way was counteracted by a ritualistic nursing of the fetishistic object. He would wash and clean the youths, reassure them that nothing deleterious had happened, and through speech and conversation create a sort of benign amnesia about the whole episode. He rarely repeated these experiences with the same person. The person who became his first stable, social, and affectionate love-object was a circumcized youth, and by then his fetishistic manic pursuits had given way to a depressive hypochondriacal withdrawn state where the true nature and extent of his ego-pathology became fully visible. Before I discuss this I shall summarize the three main motifs that were enacted in myriad, amorphous, and fragmented ways in the relation to the fetishistic object and the foreskin fetish: (i) the wish to have a baby, i.e. give birth; (ii) the erotization and control of rage and murderous impulses regarding the mother, father. and siblings; (iii) the craving for, and dread of, a passive masochistic sexual surrender, which was the most potent unconscious wish and also a threat to the unity and existence of the ego.

The wish for a baby in the male child and its specific importance for fetishism has been discussed by Kestenberg (1956), van der Leeuw (1958), and Socarides (1960). They have further related it to Winnicott's (1953) concept of the transitional object. Van der Leeuw has postulated that 'the transitional object is not only breast and phallus, but also the child made by the mother'. In my patient's ego-relation to the fetishistic objects there was the expression of the wish for a baby in terms of endowing the youths with a new identity and sense of self, and facilitating 'a psychological birth' in them. They were for him, in the context of the excited interchange, his creations, his babies: his own ideal self born through his psychological actions and activities in their shape and contour. The identification with the procreative, active and omnipotent mother was obvious here. But also present was the knowledge of its impossibility, hence rage and sadistic attack. This expressed itself through the compulsion to break down the identity of the whole fetishistic object into the regressive part-object, the foreskin fetish. The psychologically enhanced self-esteem of the 'created' youth was 'murdered' through sexual attack on it. The same theme expressed itself in the relation to the foreskin fetish: the mouth-manual-cannibalistic relation to the glans penis was the vehicle of the wish for oral impregnation. The unconscious fantasies behind making the glans penis emerge and submerge the foreskin and making the youth look at it, as well as making the glans penis enter and retract from his own mouth (vagina), were all variations on the theme of giving birth to the self and the youth, symbolized by the penis. It also served the function of reassurance against being devoured. One element of castration anxiety in this patient was the dread of being eaten up (overwhelmed) by the mother.

This also ended in a fiasco through ejaculation and here the sadistic delight in their helplessness at the point of orgasm and the consequent detumescence of the penis were in his unconscious fantasy an attack on the pregnant mother and her baby-phallus. The swallowing of the semen now endowed him with the magical power to impregnate and the use of the foreskin as (vaginal-mouth) sac for his 'intercourse' was a wish both to impregnate and to be born from this foreskin-uterus. This also ended in discharge-futility, and was followed by psychological nursing of the fetishistic objects and the need to reassure them as well as to re-establish psychic mental distance between the self and the object. The third element, that of the masochistic passive wish for total surrender and the dread of it, we see in his coercive stimulating the youths to a pitch of intolerable sexual excitement. Their egos. and not his, experienced the abandon to excitement. This way of splitting off the masochistic passive wish, projecting it onto the youth and then making them live it through his kindly sexual ministrations was one of the self-protective functions of the fetishistic practices (cf. Khan, 1962, 1964c).

Klein (1932) has detailed the complexity of the boy's fantasies in the 'feminine phase' of development. She has designated it as 'the period of maximal sadism'. She postulated: 'In this phase the boy has oral-sucking fixation on his father's penis, just as the girl has. This fixation is, I consider, the basis of true homosexuality in him.' In the fetishistic fantasies and practices of my patient the regression from the phallic phase to this feminine phase is explicitly clear, with all its omnipotent sadistic wishes to enter and possess the father's penis, as well as to attack the body-contents of the mother's inside. One consequence of this regressive intensification of the 'feminine phase' fantasies and part-object relations was the dissolution of his emergent phallic identity. Payne (1939) stated in her discussion of fetishism: 'The weakness of ego development is one aspect of the weakness of genitality and denotes interference with the libidinization, formation, and integration of the body ego, especially of the penis imago. This brings about an exaggeration of the first mechanisms and an exaggerated dependence on the introjected objects, but no sustained identification with any.'

The regression from phallic strivings in my patient led to a basic diffusion of the penis imago as a narcissistic model of self and the collusive sexual relationship with youths was an attempt to seek reassurance against the disintegration of the penis imago. In this aspect relation to the fetishistic whole-object was a defence against the persecutory anxieties inherent in the fantasies belonging to the foreskin fetishism. Sight of the whole-object as a sexualized phallic object also reassured against anxieties relating to sensations of the changing size of the phallus in sexual behaviour (cf. Greenacre, 1953).

Ego Pathology and the Disturbed Mother-Child Relationship

The analytic work of the first sixteen months had gradually enabled the patient to tolerate his inner panicky anxiety states without immediate flight into the idealized and erotic reassurance of the sexual practices with the foreskin fetish. Correspondingly he began to be disillusioned about his relation to the fetishistic objects. They were not such ideal and lovable human beings after all. He could now see that his programme to provide love for the 'outcasts for whom life had made no provision' had not succeeded, for three reasons: (i) his inability to love. (ii) their inability to receive love, and (iii) his choice of youths who had psychopathic, delinquent personalities, verging on the criminal. It was very humiliating for him to acknowledge that they had never cared for him, had stolen his money and goods, and treated him with scorn and derision.

He could now say that he did not want anyone to be dependent on him. He wanted to be dependent himself and be loved and taken care of. In this mood he began to search for a more human and what he had described as a 'personable' relationship. He met a youth and started a relationship which was neither fetishistic nor compulsively sexual (Khan, 1965). The youth was circumcised and quite a decent person. It was this relationship that revealed the true nature of his ego-pathology and the extent of his identifications with his mother. Soon after starting this relationship he found himself delusionally jealous and hysterically emotional all the time about the activities of the youth. He lived in a nightmare state of anguish when the youth was away, compulsively imagining the latter being seduced by someone else. His state of imperturbability gave way to fits of raging jealousy and a crazy sort of possessiveness. He would question the youth, endlessly row with him, search his underwear for signs of sexual activity, etc. Meantime he himself was furtively faithless to the youth with others -- as his mother had been.

He now began to realize this was exactly how he had seen his mother behave to her second husband. She felt wronged, betrayed, jealous, and inconsolable. The patient had been her chief confidant and had shared all her moods and sympathized with her grievances. His stepfather had often remarked to him that he should not take every statement of his mother's as if it were God's written word.

The relation to this youth had led to the recurrence of his two old symptoms: anal itching and nightmares. He scratched himself furiously at night and could not sleep because of ghastly nightmares which frightened him so much that he could never remember them. They had mostly to do with a physical sense of body-dismemberment and/or fantastic enlargement of certain limbs. These latter he could experience in fleeting sensations during wakefulness as well (Greenacre, 1953).

Here we were able to identify another motif in fetishistic practices with the foreskin: the sadistic wish to dig into another's body and discover the truth -- to rob it of its precious contents which were his right and were being withheld from him. His anal itching also led to a general state of hypochondria. Gillespie (1940) and Greenacre (1953) have stressed the importance of hypochondriacal states in fetishistic perversion. In this patient the hypochondriacal states could be divided into two distinct moods: (a) those relating to acute sense of personal unworthiness and loss of self-esteem, and (b) those relating to a disgust with the personal body and its secretions. They were intrinsically related to his jealous fits of rage about his new friend and his dread of being abandoned. This dread of abandonment was also a recurrent theme of his mother's emotionality. She had two terrors that ruled her life: (a) of being deserted by her husbands, and (b) of poverty, of being left destitute.

The history of his relation to his mother as we reconstructed it now from his memories, his acting out, and his transference relation can be presented schematically as follows.

His mother, a beautiful young woman, had started on her adult life rather traumatically. Her father had committed suicide and the ambitious girl had decided to make a rich and secure marriage. She had married an affluent farmer but had been unfaithful to him throughout (by her own confession). When the patient was 2¹/₂ years old she had conceived extra-maritally and this had led to overt discord between her husband and herself. She had dealt with the guilt and anxieties about her pregnancy by turning passionately to her youngest child (my patient) and had taken over from the nanny who had looked after him till then. The nanny had stayed on till the divorce four years later when she had been sacked for telling the children that it was not their father who was a nasty man but their mother who had been a fickle wife with loose morals.

It was in this context that the three memories of the wish to suck his father's penis, the wish for union with the urethra of the geldings, and his sitting on eggs imagining he had laid them began to he integrated into a more meaningful pattern. We could see how the young child had reached the beginnings of the phallic phase. The parental discord and mother's pregnancy had a traumatic effect on him. He had reacted to it (a) with the wish to be like his mother and have a baby from father (h) the dread of father's penis and rage at it (and the baby as father's penis) expressed in his biting the rhubarb plants, (c) the response to the sudden influx of insecurity in the mother and her involving him with it by flight to a magical fantasy of being united to the urethra of the geldings. Here the urethra meant the father's penis as a hollow womb-like secure place as well as the safe inside of the mother.

The patient as a child had made repeated observations of his mother's body and his younger sister's genitals. His mother had kept up a curious myth of the innocence of childhood and had exposed herself frequently, though in-advertently, right up to his eleventh year. She had stopped when one day she suspected he had started to masturbate and had then volunteered to tell him how if boys rub their penis a white fluid comes out. The relation of all these elements of his childhood experiences with the mother to his fetishistic practices was clearly established in his treatment.

His current relation to the youth settled down to a relatively stable and affectionate bond between them. He also had to accept that the youth helped him more than he helped the youth. Here the futility of his childhood efforts to help the mother, soothe her impassioned hysterical states, reassure her against her dread of abandonment and poverty all came to the fore. We could now see how the restitutive element of providing sexual pleasure to the fetishistic object was a great asset to him. He had grown up feeling and seeing that people only traumatize and hurt each other and are inconsolable.

In the treatment he now started to sink gradually into total apathy, inertia, and a help, less state of bleak withdrawal. All his phobias returned as well. He felt he could not face people and had an excruciating sense of his inadequacy and poverty of being. He could not go to work and took two years' unpaid leave, which was granted him. He now contacted his father whom he had not seen for over thirty years and who agreed to pay his living expenses.

The patient's state became one of a deep regressive dependence, in which the only thing that kept him going was his treatment. This phase lasted for nearly a year. It repeated in all essential elements the way he had lived his youth before his sexual acting-out had started. Once he had left home and gone to boarding school he had become a shy, timid, withdrawn boy. He had made no friends; lived by his fetishistic reveries and masturbation. Even though he had done well at the university and got a good degree he had not felt up to the rigours of a competitive professional life. After his college life he had felt so frightened of going mad that he had decided to become a labourer and worked in a coal mine till the war started. Soon after-wards he had been called up and was taken a prisoner of war. He had survived the frightfully arduous and dismal existence in a Japanese camp without much sense of the dangers involved—at one time he had said how to him it had felt like being in a lunatic asylum and no more. The grim reality of the Japanese prisoner-of-war camp rationalized his worst terrors. His apathetic mood and mechanical obedience saved him from being victimized by the Japanese soldiers. After the war, when he returned home, he had been given a good job and advised to have psychiatric treatment. This had led him to his first analysis and the acting out of his fetishistic masturbatory fantasies into actual relationships.

In his regressive illness in analysis the patient again decided to become a labourer because he could not bear the emptiness of his life, and it was indeed most painful to watch him live it. This alone, however, enabled us to work through the traumata of his relation to his mother.

We could now see how his mother's seduction of him as a child, which he had passionately reciprocated, had made no allowance for his emotional and developmental needs. He had felt unloved, abandoned, and terribly frightened. Added to this was the weight of the mother's hysterical emotionality. He had dealt with it by surrender to her moods and seduction on the one hand and a secret splitting off of his personal self into the masturbatory fetishistic reveries on the other. This had constituted the only private life his mother had no access to or control over. I cannot detail here the complexity of the material and analytic work involved in this phase. At the depth of his depressive apathy, phobic withdrawal, and feeling of total collapse the patient had the following dream which tells the whole story very vividly:

On a table is a rectangular bowl three to four inches high, generally used for fruit or flowers. It is full of turds that look like sausages and bananas. He feels an acute sense of apprehension that at any time the pretence will break and they will be visible for what they are. There is a bit leaning over the edge of the bowl and from its soggy consistency he fears it will break off and fall. He takes it with a silver spoon to save it from falling on the table-cloth. Pretending it is a sausage, he puts it into his mouth, discovers it is shit and spits it out.

This dream succinctly portrays the patient's inner emotional perception of his relation to his mother (the spoon in the dream had been the one given by his mother) and to the foreskin fetish. Here we see behind the idealizations and denial the true picture of the depressed deprived child's feelings of despair (cf. Spitz and Wolf, 1949).

This dream, which is from the middle of his fourth year of analysis, led to the discussion of his attitude of negativity. He now described himself as an un-person, someone who has never existed, never really experienced anything. All his life he had merely precipitated events and had remained aloof and dissociated from them -- an onlooker, neither nourishing nor nourished. Another theme parallel to this attitude of negativity was his secret sense of being special, that inside he had a very precious something which he could never share, hence could not experience himself either. One cannot exaggerate the life-saving value of this illusion for this patient It enabled him to survive his adolescence and the regressive depressive apathy in analysis. He had often felt quite objectively that there no point in his going on living, but he could not kill himself. He was external to this ideal inner self and he had no right to destroy it.

This led to his anxieties about

(a) over-stimulation through identification with the mother, the castrated sexual mother;

(b) fear of being emptied out, left totally vacant like a shell, and abandoned, i.e. being robbed of primary self and breast-mother;

(c) dread of his own wish to surrender to the sadistic mother and an acute anxiety about passive annihilation;

(d) dread of males and an archaic form of castration anxiety.

The fetishistic practices had reversed these fears. It gradually became quite clear to the patient that his passionate love of his mother in his childhood had been very shallow. Basically he had sealed himself off and lived a pseudo-existence through identification with her moods. This in turn had made masculine-phallic development impossible. He had not really participated. Very early on he had split off into two persons: the clinging phobic anxious child intimately tied to the mother and the negativistic withdrawn boy fixated on his fetishistic internal objects. His attitude to everyone had been one of phobia and paranoid suspicion. He had later added to this a cunning use of language which cancelled all relationships through verbal badinage.

This patient as a child had reacted to the ugly discord between his parents with a regression to a very private and encapsulated state of fantasy. His schematic memories witnessed this and his fetishistic practices enacted it. What characterized these fantasy states was an unintegrated mixture of the most archaic feelings, part-object relations, and excessive erotization. Payne (1939) and Gillespie (1940) have emphasized the importance of sadism and introjection-projection mechanisms. Gillespie (1940) has further stressed the admixture of incorporative tendencies with phallic strivings. In the contents of my patient's fetishistic fantasies all these elements were grossly and flagrantly present. In fact, I consider that one of the primary functions of his creation of fetishistic fantasies regarding the foreskin was to encapsulate and control these very primitive and sadistic impulses. What constitutes the specific threat to the fetishist's ego is the regressive fusion of phallic stage strivings with oral and anal impulses and part-object relationships. In my patient's childhood the mother's overt hostility towards, and de-valuation of, the father, and the sudden and violent break-up of the home led to the child's:

(i) identification with the mother, both as a source of security and a denial of castration threat from the father;

(ii) feminine identification with mother as a way of maintaining internal possession of father (penis);

(iii) regression to part-object aspects of the parents (father as penis, mother as vagina-foreskin) and the attempt to concoct a parental couple through an amalgam of these two part-objects in one foreskin-penis;

(iv) collusion with mother's passionate emotionality, the over-stimulation from this leading to excessive sexualization of these fetishistic reverie states.

The anxiety states which this patient had experienced in childhood were diffuse and acute, verging on panic all the time and yet without much psychic content to them. He could all too easily feel depersonalized and terror-stricken, to which he reacted with either apathetic depression or acting out. or hypochondria. He felt a threat of disintegration and annihilation was forever nagging at him inwardly. It was this type of anxiety state which had exaggerated castration anxiety. In the fetishist, as Greenacre (1953), Payne (1939). and Gillespie (1952) have emphasized, it is the more archaic anxiety-states that over-load castration anxiety at the phallic phase. This patient's ego had reacted to it by dissociations. These dissociations in the ego were maintained through denial, omnipotent idealization of mother, regressive use of incorporative mechanisms and their sexualization and the total suppression of sadistic-aggressive behaviour.

Payne (1939) has singled out the specific importance of sadism and the failure to integrate it to sexuality and ego-process in the fetishist. She stated that the sexual aim in the fetishist is to kill the love-object. I have shown earlier how in the fetishistic practice the ejaculation of the partner and consequent detumescence were experienced unconsciously by the patient as 'sexual murder' of the penis. The awareness of this murderous wish then led to attempts at undoing through tender nursing and care. In this the fetishist's ego is very like the obsessional's: it continuously oscillates between an archaic wish for sexual fusion and a murderous attack on the object. Both processes intensify the ego's need for self-protection. It is this that leads to exploitation of phobic attitudes a deadening of affectivity in the fetishist. The fetishist's relation to his object is more a sexualized ego-interest than an instinctual investment and love. Gillespie (1939) has pertinently remarked that in the fetishist 'the theme of satisfaction is dependent on frustration, or rather a sort of partial frustration', and that one of the safeguards needed by the fetishist is 'just that he should be frustrated'. In my patient there was never once an experience of full sexual satisfaction. Satisfaction meant extinction and annihilation. It entailed either the ego's surrender to a masochistic archaic wish for total incorporation or a sadistic annihilation of the object in the excited state. Sexuality was exploited only for erotization of defences and archaic frightening part-object relationships. What Anna Freud (1952) has described as negativism and dread of emotional surrender in the pervert is a further aspect of this threat of annihilation.

In this patient the separation from the father and the involvement with mother's emotionality sabotaged the phallic strivings and development and over the course of his childhood and adolescence led to fixations on fetishistic reveries and diffusion of his identity both as a male and as a person.

Conclusions

I have discussed material from the treatment and life-history of a male homosexual patient who had suffered acute ego-distortion from a pathogenic involvement with his mother's mood and personality from the age of 3 onwards. The questions I want to ask are:

(i) why the patient as a child did not develop a severe psychotic illness?

(ii)what enabled him to create so early a fetishistic inner reverie state that protected him against total surrender to the mother's pathological intrusions upon his personality?

I think it is feasible to answer that the ego's capacity to dissociate and create a fetishistic reverie protected it from total submergence in mother's pathology. The libidinization from the mother also facilitated the stabilization of the fetish. The fetishistic reveries protected the ego against psychotic breakdown. What had compelled the patient to seek treatment was the unconscious knowledge of the threat to his ego through acting out of the fetishistic fantasies. The question as to what enables a child to create a fetish is not so easy to answer. In my patient there was certainly a good early feeding relation to the (breast) mother and to a stable healthy nanny. It was around the beginnings of the phallic phase that the traumata began to happen. The emergent oedipal (negative and positive) relations were disrupted by these traumata and a collusive pre-oedipal regressive relation to the mother materialized instead. The maturational processes and growth enabled the ego, however, to fight a defensive self-protective battle through dissociation and regression. I have tried to show how the fetishistic object and the foreskin fetish comprised the early infantile self and the primary object (mother). The fetish is built like a collage: it envelops complex and archaic affects, psychic processes, and internal part-object relations and manages to sustain them in an unintegrated state.³ I am inclined to say that in the capacity to create a fetish we see the inherent strength of the infant-child ego and its capacity to save itself from total collapse and disintegration. The capacity to create a fetish presupposes that maturationally the ego has access to its synthetic functions. The basic mechanisms involved are: splitting, denial, isolation, idealization, somatization, objectivation, and sexualization. The primary anxiety affects relate to dread of surrender to excitement and the exciting object, sadism, and threat of body-dissolution, and annihilation and being abandoned. The fetish is both a phobic and a counter-phobic phenomenon. This duality of the fetishistic phenomena relates them closely to obsessional states. Through the fetish the ego tries to find a way out of its negativity and paranoid withdrawal and through the process of sexualization tries to bind the aggressive, sadistic, and uncontrollable rage impulses. The fetish enables ego functioning and object relationships, the extreme obverse of which is autistic withdrawal.

³ Dr Hanna Segal in her discussion pertinently pointed it might be more accurate to define the fetish as a portmanteau. In this patient the fetish (as a reverie state and object) was a container of very archaic and primitive psychic and sexual processes.

The interplay of two distinct types of psychic processes are prominent in this patient: one related to his ego-functions and the other to sexual excitement. The ego-functioning had been crippled by a severely apathetic, phobic Etude throughout the childhood, adolescence, and youth of this patient. During this period he had maintained a highly organized excitement and emotionality in which masturbatory fantasies about the foreskin-penis were the dominant integrating factor. The case history shows how the patient as a child had reached a rudimentary phallic phase of psycho-sexual development. These intense phallic-genital excitements had been both sponsored and encouraged by the contemporary care-taking environment and object-relations. The breakdown of the parental environment had led to a chaotic regression to pregenital modes of oral-anal incorporative fantasies, but the penis-imago had been retained throughout these vicissitudes, though in a pathologically dissociated precarious state. Henceforth the most striking feature of this patient's internal reality was the intense and amorphous excitement that this foreskin-imago could mobilize in him. I have also suggested that these phallic excited sexual states operated as a manic defence (Winnicott, 1935) and were exploited as a defence against acknowledgement of the disruptive upheavals of his childhood and the consequent threat of ego-disintegration, despair and dissolution of personality. He had later found a way out to reality and object-relationships through acting out this encapsulated phallic-cum-pregenital amalgam of internal excitement and sexual frenzy. This had enabled him to achieve a pathological ego-mastery over his impulses and the object as well as to force his ego out of its phobic-paranoid attitude of apathetic mistrust. But if this acting out had served the function of a rescue operation, it had also threatened him with a total loss of self through surrender to sexual impulses and the object. He had sought treatment because of his amorphous state of lack of identity and purpose in life. I am proposing here that this type of internal anxiety-situation constitutes the basic predicament for the fetishist. Fetishism is a state of omnipotently, but precariously, controlled mania. Hence it is at once intensely pleasurable and frightfully vulnerable. What the patient had sought from his treatment was the assimilation of this manic sexual fetishistic excitement and affectivity into an ego-capacity that could be related to the self, the object, and the environment. This he has certainly achieved through his analysis. During the past ten years since his analysis, the patient has lived an active and creative professional, social, and intellectual life as a member of his own culture, doing good work in an atmosphere of social belongingness.

Freud from the very beginning had stressed the crucial role of castration anxiety in the genesis of fetishism. Researches since then, particularly those of Glover, Payne, Gillespie, and Greenacre, have emphasized the role of early internalized anxiety-situations, object-relations, and vicissitudes of body-ego development which characterize the peculiar intensity of the fetishist's castration anxiety. In my case-material all these factors are vividly present. This case history tries to show how these early anxiety-states and excitatory experiences reinforce the castration threat in the fetishist. Furthermore, it is possible to point out from where the as-if adult quality of the fetishist's sexual exploits and behaviour derives its egosyntonicity. It is the phallic-genital excitement that holds the dynamic clue (cf. Katan, 1964). At the point of childhood traumata both the ego and psycho-sexual development have achieved phallic status though they are not stabilized as yet. The regressive process brings with it an influx of pregenital impulses and archaic psychic functioning. This regressive process is collusively reinforced by the mother's behaviour in many subtle ways (cf. Greenacre, 1960). Hence the bizarre, hopeful, and absurd nature of all fetishistic phenomena. The mutative factor, however, remains the intensity of phallic affective excitement and the regressive intrusion of pregenital part-object relationships in the fetishist. The omnipotent control of the object to discharge this manic phallic excitement is a most characteristic feature of the fetishist personality. Through it the archaic part-object relationships are held in control. This does not reduce the threat to ego-stability in any way. In fact, it exaggerates it. The very media by which the fetishist is compelled by his internal anxieties and impulses to seek reassurance, through collusion with external objects and reality, expose the ego to severe and persistent danger-situations. Hence the acuteness of the threat of castration (annihilation) and ego-collapse in the fetishist. The ego is never in full mastery of the internal crises or external objects. The exploitation of primitive mechanisms, like splitting, projection, incorporation, and idealization by the ego, in order to create the illusion of omnipotent control interferes with its normal functioning. The fetishist achieves his sense of security, self-esteem and well-being entirely through his manipulation of the agitated excitability of the penis-imago and the complex archaic pregenital impulses and object-relations inherent in it. This exploitation increases the threat of over-stimulation to the ego and faces it with the predicament of either total exhaustion and annihilation or masochistic surrender to the object. The failure to neutralize sadistic impulses and their fusion with libidinal strivings without modification of murderous intent exaggerates further the threat to the object and the retaliatory threat to the self (Payne, 1939).

It is in this internal constellation of pregenital sexual impulses, primitive object-relations, and affectivity that we can fully decipher the necessity of the maternal imago as a phallic object for the fetishist. Freud (1927) had explicitly stated that the psychic content of fetishistic practices is the fixation on the phallic mother-imago: 'the fetish is a substitute for a woman's (the mother's) penis that the little boy once believed in and—for reasons familiar to us—does not want to give up'. My case-material suggests that the phallic mother imago upon which the fetishist is fixated is composed from sensations derived from the self-phallus in the excited states and the maternal object towards whom these are directed. Also involved are passive longings for the father's penis. Through a tour de force of psychic functioning the fetishist in his childhood creates a unitary imago from experiences and characteristics that belong to two different persons: the self and the object. I have shown how the foreskin fetish in my patient had attributes both of the self and the mother as well as of the father. Once these features have been coalesced they are dissociated from reality-testing vis-a-vis the external object. It is at this stage that denial plays such an important role in the psychodynamics of fetishism. It is this that relates fetishistic phenomena specifically to transitional object type of psychic functioning (cf. Winnicott, 1953). The instinctual regression is reinforced by ego-regression to more archaic and magical forms of psychic functioning. The fetish is created out of the sensations of self-body and object-perceptions. The threat to the body-ego from anxiety of annihilation (castration) is averted by projecting the penis-imago to the mother, who is then incorporated as a phallic omnipotent object. This has the added advantage that not only is the threatened penis-imago rendered safe but the archaic bond of security with the mother is also re-established. Similarly, the father's penis is internalized as a magical food-object. The maintenance of this complex affectivity and psychic functioning entails severe curtailment of the ego's growth and development. Hence the fetishist is a person deluded by the certainty that he has access to, and omnipotent possession and control of, a magical object.

The fixation on the internal magical object interferes with the neutralization of aggressive and sexual impulses in the fetishist. The specific ego-pathology in the fetishist thus relates to the failure to establish 'secondary autonomy'. Hartmann (1964) defined his concept of 'secondary autonomy' as:

...many, though not all, ego activities can be traced genetically to determinants in the id or to conflicts between ego and id. In the course of development, however, they normally acquire a certain amount of autonomy from these genetic factors. The ego's achievements may under the circumstances be reversible, but it is important to know that in normal conditions many of them are not. The degree to which its activities have become functionally independent from their origins is essential for the undisturbed functioning of the ego, and so is the degree to which they are protected against regression and instinctualization. We speak of the degrees of this independence of the ego as the degrees of secondary autonomy. (Hartmann, 1964, p. xi.) In Hartmann's idiom we could postulate that fetishism is a pathological substitute for 'secondary autonomy'. It is this specific type of ego-pathology that accounts for the complexity and bizarre qualities of the fetishistic phenomena.

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