I feel compelled to make a preliminary comment in regard to "cockroach-longevity" spam - in my case, in the form of a truly astonishing number of (purported) sites employing an astonishing variant of the human name attempting to avoid filtering - who make my email an object of considerable annoyance. And so it goes... But standing out from among this clutter of detritus is a (purported) MD, Ph.D., GR, who "raves" at my blog content (thereby immediately making himself a focus of suspicion), and offering to make me something of a net healthcare celebrity. As near as I can tell, his deal is attempting to sell "traffic" to your site as a pitch to assume your content. Once (and once only) I was, in fact, polite in rejecting his offer. Now that I have removed the hook from my lip for ever responding & thereby opening Pandora's Box, I conclude this short rant by stating, "Dr. GR, fuck you and the horse you rode in on." Perhaps now he will conclude (if he has ever read this blog at all) my content is unsuitable for his vast readership. Desperate measures...

In my mind, the details of sexual activity is a sensitive, uncomfortable issue. I do not mean to imply that I am "prudish," or "squeamish" around the discussion of sexuality: as a practice, I always inquire if a patient is sexually active, if they have been tested for STD's (notably HIV/HCV), and if they employ safe sexual practices; and likewise, I always inquire if a patient (male or female) has experienced sexual abuse. I find that all of this information is essential to good clinical practice, but is rarely "offered" unless specifically asked. Nevertheless, I have long believed in what has been so dramatically, elegantly, and profoundly elucidated by the Russian philosopher/theologian Paul Evdokimov: sexuality is defined in intimacy, and conversely, intimacy is defined in sexuality. And in fact so intimate as to be a literal act of human transcendence (the paucity of such events, it would seem to me, makes it difficult to argue) as to be placed beyond simple "scrutiny." Mind you, please: I am neither a philosopher, theologian, a particularly "deep" thinker, nor did I ever meet Evdokimov. I can reasonably imagine he might conjecture "deviance" or "aberration" as inconsistent with a "transcendent intimacy" - but I cannot speak for him - nor will I speak to the "conditions" (read the book!). Nevertheless, I strongly suspect he would not be surprised at the level of angst and/or ennui we so frequently observe in clinical practice as relates to issues sexual. As a clinical instructor noted, "Sex will fuck you up." And so, to the termination...

My "adult film industry" patient is only the third I have accepted into treatment (which is generally 3 more than any of my colleagues) and which also includes two which I did not, but I make no claim to be knowledgable. And apart from an attempt to fathom a definition of intimacy within the context of "the industry" (and all five referred to the "players" in a general cloak of "the industry" and "the talent"), the dynamics do not interest me particulalry. Further, my pursuit into this context, frankly, left me feeling a touch foolish and naive; managing, I suspect, to elicit every stereotype I ever had rearding the "production" of pornography.

My gentleman presented as markedly depressed in affect and demeanor. He walked in a sort of stooped way, avoided direct eye-contact, and though quite young, fell into the chair with a sigh of breath. In a good-natured opening (and God knows I'm good-natured), I explain that it is my practice for physician & patient to "interview" one another, and in the end attempt to come to some conclusion as to whether the patient believes I might be of help, and, likewise, if I believe I might be helpful. As with a good 60-65% of new patients, he indicated, "I don't exactly know why I'm here." I believe I then, imperceptibly, sighed. The work begins. As a clinical instructor once reported, "I ask enough questions until an image of what I believe the "issue(s)" might be begins to crystallize, and I continue until I have a working hypothesis." OK.

This gentleman reports a "dead end," going no where" lifestyle that he perceives makes him unattractive to would-be companions, and he is lonely for a "real relationship." "What does this mean?" "Well, I work in the adult film industry." And here begins, at least in my mind, a blowing of the dust off every stereotype I have gleaned from Boogie Nights; 2 documentaries relating the stories of porn "actresses," otherwise "girls-next-door" types who, in a frenzy of drugs, sex, and disillusion, complete suicide; a Rolling Stone biography/obituary of a spectacularly-endowed "pioneer" of porn who succumbed to drugs and AIDS; a "panel" of actors/actresses on a "talk show";and the biography of a male porn actor, required reading for a course on Human Sexuality that, to this day, I perceive as seduction rather than education; we won't go there.

The patient before me bears absolutely no resemblance to any of my stereotypes: virile; attractive; (at least for the camera) out-going & uninhibited; comfortable with himself & his sexuality (though I'm not exactly sure what this means); and, seemingly, enjoys his work. Well, it turns out that my patient is not an "actor," but on the "production side" of gay pornography (an "industry" I assumed flourished farther north in Los Angeles): greeting potential "talent" (Semper Fi, indeed), making them "comfortable" ("They're pretty much always nervous when they arrive") and preparing them for the shoot" (No, I didn't ask); adjusting lights and "scenery"; and "cleaning up" (you knew somebody had to do it). Pointedly, the patient stressed that, despite engaging in "activities" relevant to the task at hand, "I am not gay or bi." Thus, with the summation of the facts, while I am confused, he, apparently, is not, and that is all that is important. Or is it?

What shall we make of the word angst, and does it have have a place in psychiatry? While I do not believe you will find it in the DSM-IV or Kaplan & Saddock, it is certainly a familiar concept in psychiatry. From my reading (and acknowledging a limitation in translation) angst seems, in the vernacular, to infer both "anxiety" and "panic." If I read Kierkegaard correctly, angst is a: "byproduct of drifting, or more specifically, the absence of rules, form, and shape that accompany it [and thus "panic"]. There is a hegemony of rules & shapes and laws precisely because we feel chillingly uncomfortable without them." Later, "This dread is explicitely connected with freedom and choices, with the uncertainties and lack of boundaries that freedom entails..."

Deep within every human being there still lives the anxiety over the possibility of being alone in the world, forgotten by God, overlooked by the millions and millions in this enormous household.''

Now, if you're like me, you hear a profound echo - freedom inextricably bound with anxiety & panic - and know it to be Irvin Yalom in Existential Psychotherapy: yes, the primitive drives, plus the terror of death and the dilemma of freedom. Freedom, the drifting with an absense of rules, boundary, and laws, by a seeming paradox, unhinge us. Ironically, while lacking the fundamental curosity of Kirkegaard or Yalom, and, without my pejorative intent, I suspect without even appreciating the content, porn filmaker Holly Randall writes about the "pornographic angst":

With high-end productions pushed to the side to make way for amateurish, extreme content, we created a market for what I call the Porn Olympics. It wasn't about the beauty and sexiness of the girl anymore, it wasn't about the chemistry between the performers, or the setting, or the quality of the production. Now it was a question of how far you could push the envelope: how many men can you have sex with in one film, how many ***** can you fit in your orifices, how many ways can you eat ***? In the attempt to one-up the last guy, scenarios I couldn't even dream up became, well, somewhat normal.

What happened to good old-fashioned, passionate sex scenes? You know, the ones with the beautiful women, the gorgeous settings, the beautiful clothes and superior lighting? Oh that's sooo boring…. I mean, who can get off to a scene if someone's head doesn't get pushed into the toilet while getting ****** from behind?

Better we move on to ennui and sum up my observations...