Sometimes doctors are given second chances, and it is possible that the belated recognition of the ‘teacher’ who was provoked in the doctor and nurse by the patient will make it possible to explore the ‘childish’ behaviour at the next visit.
Other feelings in the doctor can be seen to have developed in response to the patient. Irritability, anger and even a particular degree of sadness or despair become subjects of study. Indeed, the feelings may be projected from the patient, via the presenting doctor, into the group. For instance, unconscious aspects of the patient may be seen particularly clearly when her or his ambivalent feelings reveal themselves by a split in the feelings and sympathies of the group members themselves.
Contraceptive consultations are favoured occasions for revealing overt or covert sexual problems. By attending for advice on birth control, patients are already revealing that part of them that is sexual, and the subject of difficulties with their sexual life can be broached with less difficulty (it is never easy). Doctors and
nurses concerned with giving contraceptive advice should be comfortable discussing sexual matters. They need to be skilful in their ability to receive and manage their patients’ confidences and to recognize when and how to refer those they are unable to help.
Expectations of what will happen during consultations for family planning influence the choice between clinic or general practice, or between known or unfamiliar doctors.
Patients may attend a community family planning clinic because they have heard that patients have a ‘thorough examination’ there. On the first attendance the patient may look disappointed when she is told that the examination of that (sexual) part of her body – her genitals and breasts – can be left until later. She wants an examination of this part of her about which she has unspoken anxieties -perhaps doubts that it is ‘good enough’ to be shown to a partner, or that, untried, it may not function well enough, or might become out of control.
A very anxious and distressed woman in her mid-30s came into a family planning clinic asking for postcoital contraception because of extramarital intercourse the night before. She explained that she was married to a long-distance lorry driver and they had three children. Four years previously her husband had undergone a vasectomy. Since then she had been surprised to find she could not allow sexual intercourse. She said she had never enjoyed it, but had assumed that things would improve once the fear of pregnancy was removed. Instead, she was devastated to find there was a marked deterioration. The doctor asked her why she thought this was so, and she said she had found it more exciting when there was a chance of pregnancy. Then she added that she did not think it was fair that her husband could now behave as he liked on his frequent absences from home, and that he need fear no repercussions now that he was sterile. The doctor asked if she had been distressed about her husband’s infidelity before the operation, and she said she had preferred not to think about it then. Although she had been angry, she had been so busy she had put it to the back of her mind. Recently, she had become frightened about her own lack of sexual feelings and she had drifted into a casual relationship with a friend, to see if she could respond to a fertile man.
‘In general, Third World service programmes are primarily accountable to their governments and/or western donors who fund them.. They often have demographic rather than service priorities’ (International Women’s Health Coalition, 1986). Thus individual needs and the quality of the service are pushed down the list of priorities, and the acceptability of a method and greater security against pregnancy are considered more important. The service can become completely impersonal; for example, in Mexico it is policy that 90% of women who have a termination of pregnancy should have an IUD fitted. In Indonesia, poverty certificates have to be shown for access to some contraceptive services. Moroccan women queue in waiting halls without their underwear, to speed up throughput. It can be seen that the needs of women and the needs of the population can be at odds when resources are limited.
Because masturbation is so common after puberty, the incidence figures are useless for comparisons, but certain other aspects may be profitably studied. For example, the men in four of the six groups of patterned offenders spent more years worrying about their masturbation than did the incidental offenders, the proportion being about one third for the latter and one half for the former.
Every person who had masturbated was asked what was the greatest number of times they had done so in any seven-day period. Without exception the patterned offenders reported higher figures. The average incidental offenders reported maxima of from 2.8 to 4.8 per week, while the patterned reported 4.1 to 8.1. The greatest difference existed among the peepers (2.8 to 8.1) where masturbation was a frequent accompaniment of peeping. One may speculate that high maxima may be indicative of strong sex drive and of compulsion, and one would expect the patterned offenders to exceed the incidental in these two attributes.
While the presence or absence of fantasy during masturbation proved insignificant in differentiating patterned and incidental offenders, three sorts of fantasy did reveal definite differences. In five of the six groups, more patterned than incidental offenders had sadomasochistic fantasy; the percentages were generally small except in the case of the patterned aggressors, of whom one fifth had such fantasies. Again the patterned offenders led in five of six groups in fantasies of sexual activity with animals, though the percentages were generally small. In bizarre fantasy—often fantasy related to the offense behavior—the patterned offenders exceed the incidental in all six groups and frequently by large margins. This is one of our most clear-cut findings and one which could be logically anticipated: the habitual exhibitionists have fantasies of exposing themselves, the chronic peepers fantasies of peeping, etc. With one exception, from about one fifth to one third of the patterned offenders had such bizarre fantasies as opposed to no more than 10 per cent of the incidental offenders.
The use of drugs of all types has long been taboo in American society although formal control, first through medical prescription and then through traditional criminal sanctions, has had a shorter history. The complex of psychological and social resistances to the use of drugs is not a matter to enter into here, but it is important to recognize the emotional and intellectual horror that use of drugs invokes in the citizen who does not use them. The general climate of opinion among the public is often one of hostility and anger when the subject is broached.
Thus the combination of drug use and sex offenses provokes a stronger emotional response than either event singly. The “dope-crazed sex fiend” is a traditional figure in the mass media, and the drug-provoked “sex orgy” is a traditional event in our newspapers and magazines. Personifications of such steretoypes are actually very infrequent.
The chief drugs of interest here may be grouped into three classes.
First are the opiates, both natural and synthetic. These are clearly addicting drugs to which there is major physiological adjustment and whose absence in the addicted individual causes an identifiable syndrome of withdrawal. Such physiological involvement may be taken as the distinguishing aspect of addicting as opposed to habituating drugs. The natural opiates range from smoking opium to the chemically extracted or refined products such as morphine and heroin (diacetylmorphine). The synthetic opiates which have comparable analgesic effects and addiction liability may be used as substitutes for the natural opiates.
Opiate users in the various sex-offender and control groups are of two types. Aside from persons with no experience, there are those with experimental experience, i.e., “joypopping” or “skinpopping,” and those who are truly addicted or “hooked.” From the best evidence available, and it is none too good, it is fairly clear that persons addicted to opiates seldom fully refrain from future use. Recidivism is marked and proceeds at a very high rate.
The second class of drugs consists of a single item, marijuana. This drug is smoked in cigarette form and is nonaddicting. The use of this drug is often claimed to be a precursor of opiate use and addiction, but the data in this area are very poor. There is surely more experimentation with marijuana than there is with the opiate drugs, and it is unlikely that most marijuana users go on to opiate addiction. The patterns of marijuana use are often considerably different from the patterns of the opiate users, being more sporadic and involving less criminal activity. For the purposes of this study marijuana users have been divided into experimenters and habitual users.
The third class of drugs is a heterogeneous one containing a variety of drugs with a variety of effects. They are nonaddicting but habituating. The barbiturates, the amphetamines, and other prescription drugs ordinarily used as either sleeping tablets or stimulants are part of this group. Use of these drugs for their ostensible licit purpose is not included here. Our concern is with use of the drugs for their euphoric, stimulant, or escape effects known in the argot of the user as “kicks.” Also included in this group of drugs is cocaine. A strongly hallucinatory drug, it is nonaddicting, and presently its use is rather rare. It has been employed by some sophisticated addicts when available as a part of “speedball,” i.e., a mixture of heroin or morphine with cocaine, but such use is not frequent and given its nonaddicting characteristics cocaine is included in this miscellaneous category. Certain esoteric drugs are not included, such as peyote, mescaline, or LSD-25.
The use of opiate drugs is very rare among the control group. None of this group are addicted, and only around 2 per cent ever experimented with them. The figure for the prison group is much higher, with 8 per cent having used opiates at some time and an additional 9 per cent addicted. Between these two extremes are all the sex offender groups. Experimental use of the opiate drugs ranges from none in the case of peepers and incest offenders vs. children to 8 per cent in the case of the heterosexual aggressors vs. children. The percentage in this last case represents two persons. Most of the sex offenders never experimented with opiate drugs—not more than 2 to 3 per cent of any group. Addiction to opiates is even rarer, with six groups having no member addicted, six groups with 1 to 3 per cent addicted, and only two groups with higher proportions, these latter being the aggressors vs. minors and adults with around 4 per cent.
Opiate addiction is much less marked among the sex-offender groups than it is among the prison group, and although there is generally a little more experimentation with opiates and actual addiction in these groups than among the control group, it does not appear to be related in any Way to specific or generalized sex-offense behavior.
Use of marijuana is a more widespread phenomenon than use of opiates. A single experience or a few experiences with marijuana are not unusual among persons in certain subgroups in the general population. It is like experimenting with alcohol, and generally with less consequence to the individual. Marijuana is not easily come by, and its illegal status makes habitual use somewhat difficult and expensive.
Only 3 per cent of the control group ever tried marijuana, and only one person in this group could be called a habitual user. The figure for the prison group is 17 per cent, and an additional 10 per cent have histories of habitual use. All but one of the sex-offense groups vary between these two extremes as far as experimentation and use are concerned, the younger age-of-object offense groups usually having more experimentation with marijuana (except for the homosexual offenders), but this pattern does not appear among those who use it habitually. Nearly two fifths of the heterosexual aggressors vs. children have experimented with marijuana, but none of these ever used the drug habitually. As far as habitual use of marijuana goes, only the heterosexual aggressors vs. minors exceed the prison group.
While the sex-offender groups generally use marijuana more extensively than does the control group, only in two cases does their use surpass that of the prison group. Neither the experimental nor habitual use of this drug seems to be associated with any particular or general type of sex offense. Marijuana use, like opiate drug use, is not an agent in precipitating any specific sex offense, nor does it appear to be a long-term predisposing factor.
Use of other narcotic drugs of various types among the sex-offender groups again falls near or between the very low limits set by the control group and the upper limit set by the prison group, with ranges of 0.8 to 11 per cent for experimentation and 0.0 to 6 per cent for habituation. The heterosexual aggressors vs. minors are an exception, experimenting considerably with barbiturates and amphetamines, but this is not followed up by extensive habitual use.
None of the specific types of drugs seem to bear any weight in the analysis of the various sex-offense groups, but if the total proportion of any group who have ever used drugs of any kind, experimentally or otherwise, is examined, two groups appear sharply different from the others. Taking drugs for the purpose of stimulation is characteristic of only one in 20 of the control group, but of one in three of the prison group. Two groups that are very similar to the prisoners are the heterosexual aggressors vs. children and minors.
If drug use may be assumed to stand in some relation to the “try anything once” attitude, then it is clear that the aggressor groups in general, and the aggressors vs. children and minors in particular, have a highly experimental and possibly impulsive relationship to the world. In this search for “kicks” they are similar to the prison group and their attitude is probably more related to a general delinquency than to the specific type of offense.
The use of drugs of any type could be either an index of different attitudes and situations than are usual among persons in the lower social classes, or a precipitating factor in the specific offense. There is no evidence for this latter hypothesis as far as these data go. What is evident is that most of the sex-offender groups are more exposed to all types of drugs and are more often users than are their nondelinquent peers. But since their exposure is usually no greater than that of the nonsex-offender delinquents, it is not a special characteristic of the sex-offense groups. Thus drug use is here a measure of an attitude of experimentation and general delinquency.
The techniques and extent of extramarital and postmarital petting were not ascertained in the earlier case histories; consequently our data are seriously limited. Nevertheless, we found postmarital petting, like postmarital coitus, to be essentially universal. Extramarital petting, we know, considerably exceeds the incidence of extramarital coitus, but again precise data are lacking.
However, from our later, more detailed case histories it is clear that the men we interviewed had less mouth-genital contact with their postmarital or extramarital partners than with their wives. With regard to the balance between cunnilingus and fellation we see a compromise between the premarital situation and the marital. In three groups the percentage with cunnilingus exceeded the percentage with fellation experience, while in five the percentages were essentially equal. One may speculate that while marriage had relieved much of the inhibition regarding cunnilingus, some males still balked at applying the technique to a female less familiar than a spouse.
In postmarital and extramarital life the incest offenders vs. children and adults had the largest numbers of individuals with mouth-genital activity. The offenders vs. minors and adults as usual are at or near the bottom of the rank-orders and are joined there by the control group. The high ranking of the incest offenders vs. children is no surprise. After being restrained and/or inhibited about mouth-genital contact with companions prior to marriage, we see them become quite active in this technique with their wives, and this sexual emancipation seems to carry over into their post- and extramarital behavior. The high ranking of the incest offender vs. adults, however, has no visible precedent.
The above statements are made with caution, for our calculations regarding extra- or postmarital activity were, obviously, based on males who had married, and we are aware that in different groups varying proportions of men were divorced or had engaged in extramarital behavior. A rough check , indicates, however, that these differences did not exert a powerful influence. For example, the peepers, who rank first in cunnilingus with extramarital or postmarital companions, rank eleventh in the proportion who had ever had extramarital coitus.
One standard question in our schedule concerns erectile impotence. This seemingly simple question was actually fraught with various qualifications. For example, one should not count as erectile impotence a penile detumescence brought about by some strong external stimulus such as a knock on the door. If a man reported impotence due to the use of drugs or alcohol, the explanation was noted, but we did not routinely inquire about the cause of rare or infrequent impotence, and thus “lost” some unknown additional number of instances due to these causes. Consequently we have combined our categories of “infrequent impotence” and “impotence only when drunk or using drugs.”
In our previous volume on males we found the most important correlate of impotence to be age. In this present study, however, where we are dealing chiefly with persons under fifty, the effect of age is scarcely seen. It is visible only in that our second youngest group, the peepers, had fewest individuals reporting any erectile impotence (31 per cent), whereas our oldest group, the incest offenders vs. adults, reported approximately twice as many (61 per cent). The second oldest group, the incest offenders vs. minors, ranked second highest with 58 per cent reporting any degree of impotence. Here the correlation ceases, for the group with the third largest proportion of men who had experienced impotence is our youngest group.
Aside from this rather vague but anticipated relationship with age, tabulation reveals two trends. First, all incest offenders tend to have a high incidence of impotence, ranking first, second, and fifth. Secondly, in the five groups with the least impotence are the four whose sexual behavior most closely approximates cultural norms: the control group, the prison group, and the offenders vs. minors and adults. At this juncture the reader should be warned not to place much reliance upon the figures for the homosexual offenders, since it was not always clear in the records whether the data referred to heterosexual or homosexual impotence.
The proportions reporting infrequent impotence or impotence resulting from overdosage of alcohol or drugs range from one fifth of the control group to one half of the aggressors vs. minors. The heterosexual offenders and the control group, who had few alcoholics among them, had the fewest individuals reporting infrequent or toxic impotence. The four groups with the largest numbers were two incest and two aggressor groups. Of the latter, one may suspect some psychologic impotence due to the response of the females upon whom they forced themselves; of the incest groups, age may explain the incest offenders vs. minors (our second oldest group), while the large number of alcoholics among the incest offenders vs. children may explain their standing.
A rank-order of those reporting occasional erectile impotence displays all but one group with percentages of from 2 to 10; the exception (with 28 per cent!) are the incest offenders vs. adults. It is best once again to refrain from using age as a causative factor since our second oldest group, the incest offenders vs. minors, occupies the bottom of the rank-order with 2 per cent.
A rank-order of those who reported serious and/or frequent impotence has a range running fairly smoothly from 0 to 14 per cent. The aggressors, peepers, and prison group cluster at the bottom of the scale as befits their relative youthfulness. The top three ranks (10 to 14 per cent) include our second and third oldest groups. The control group is centrally located with almost 8 per cent reporting serious impotence. The presence of all three homosexual-offender groups within the upper five ranks is, despite our previous warning, probably indicative of conflict between their heterosexuality and homosexuality.
Of those who married, 52 per cent had extramarital coitus, which places them in a low-intermediate position in the rank-order, just above the peepers. In the case of the latter, the youthfulness of the sample was a factor in the paucity of extramarital coitus, but this cannot be true in the case of the exhibitionists whose average (median) age is nearly thirty-five. The age-specific incidence figures for extramarital coitus with companions are always moderate, though well above those of the control group. From ages twenty-one to forty-five, between 31 and 37 per cent of the exhibitionists were having such coitus within any five-year age-period. Aside from one aberrant figure based on a small number of cases in age-period 41-45, the age-specific incidence for extramarital coitus with prostitutes is similarly moderate, holding between 14 and 17 per cent. The frequencies of extramarital coitus tend to be low or intermediate except from thirty-one to thirty-five; where one high-rating individual strongly affects the mean frequency. There is a strong emphasis on prostitution; these men had extramarital coitus with prostitutes almost as often as with companions. The average (median) exhibitionist who had extramarital coitus had it with five females—a moderate number and the same as that recorded for the control group. The proportion of total sexual outlet constituted by extramarital coitus with companions parallels what we have seen in frequencies: it is rather small (usually 1 to 3 per cent, except in age-period 31-35 when the effect of the one deviant individual is felt. The proportion of total outlet derived from extramarital coitus with prostitutes reflects the importance of commercial sex to these offenders— I hey manifest relatively large proportions, usually ranking first or second, just below or just above the prison group.
The exhibitionists whose marriages broke up continued to have coitus in a high percentage of cases; indeed, between ages thirty-one and forty all the separated, divorced, or widowed exhibitionists had post-marital coitus. The frequency, however, tended to be low. This combination of high incidence and low frequency results in their having derived moderate proportions of their total outlet from postmarital coitus. The difference between coitus with companions and with prostitutes is especially important here: the proportion of outlet derived from companions is moderate up to age thirty-five (61 per cent, declining to 46 per cent) but small thereafter (16-24 per cent); the proportion derived from prostitutes is always relatively large, in fact, the exhibitionists rank first to third, and the figures increase progressively with age from 4 per cent between twenty-one and twenty-five to 57 per cent between forty-one and forty-five. This same emphasis on commercial sex in later life is seen in age-specific incidence of post-marital coitus with prostitutes, in which the exhibitionists rank first from age thirty-one on, with a figure of from 67 to 90 per cent having such activity in a given period.
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