Most things I’ve read that have been disturbing (graphically or otherwise) have had the self-awareness and limitations of experience factor. It’s probably implicit to uncomfortable subjects and a big reason why there is such a divide in what people can bare to read. Some things just seem too unreal to register as an abstract lesson in perceptual issues. I think Satire/humour helps to put the relevance back where it might be lost. i.e. "Laugh so you don't cry."
I think most authors that deal with extreme or graphic imagery allways have the safety net of that particular character not bieng "normal" Patrick Bateman (American Pyscho) mental breakdown, Vaughan (Crash) death obsessed control freak, The Binewski's (Geek Love) carnival freaks. The authors allow the reader the comfort that these are "abnormal" people & therefore thier "abnormal" behaviour is rendered shocking but palitable. Interestingly the character of Miss Lick in Geek Love blurs those boundaries, a character who, from the outside is perfectly normal & respectable, yet capable of horrific deeds.
For any form of fiction, be it novel or film, unless thier is a rationale in the writing for the imagery, the acts lose thier potency. The shock comes from an understanding (allbeit a partial one in most cases) of what is happening & more importantly why. Cow's suceeds where a lot have failed. The repetative assaults on taste & decency do not lose thier impact as the central characters are so well written. Where as if you take the flipside & look at an example of a failure of the extreme it loses all impact. Take for example August Underground's Mordum. A film so utterly repugnant in imagery it has become imfamous in the Underground Horror circuit. A faux snuff movie (second part of a trilogy) where from the moment the film starts the viewer is assaulted with scene after scene of the most offensively brutal, sadistic depravity ever seen. In the first 20 minutes the viewer is witness to incest, castration, vomiting, the felating of a severed dick, wound sex, necrophillia & so on. The next 70 minutes continues with even more extreme scenes. The problem is, devoid of any real plot (there is a vague sick 3 way incestous love triangle) the viewer becomes numb to the violence. Without point or purpose & without relief if becomes hollow & unenvolving. The same could be said for a book I read years ago about Gilles de Rais (can't remember the title as it was godawful) which was just a jumble of assorted depravities with no narrative order. It failed to connect or affect.
Books like Cow's disturb because at some level we can all see it as a mirror reflecting the dark side of humanity.