In comparison to the incidental offenders the patterned offenders had a less favorable background: their parents did not get along well nor did they get along well with either parent. Possibly seeking emotional gratification elsewhere, more of the patterned than incidental offenders had prepubertal sex play, both hetero- and homosexual.

After puberty, inhibitions and worries over sex seem to have developed more markedly among the patterned offenders. They worried more about masturbation, they were more deterred from having coitus by moral considerations and by fear of disclosure, and they had premarital coitus with fewer companions and prostitutes.

At the same time, and to some degree possibly as a consequence of lesser activity and more restraint, the patterned offenders developed a greater responsiveness to the sight and thought of females and also became preoccupied with the more esoteric aspects of sex. Their dream content and their masturbatory fantasies contained more unusual elements than did those of the incidental offenders. Both before, during, and after marriage the patterned offenders show a much greater interest in mouth-genital contact, both foliation and cunnilingus. Lastly, more of them experimented with extramarital coitus, homosexuality, and animal contact.

One is left with a somewhat vague picture of a childhood of emotional difficulties coupled with sexual activity, and an adult life consisting of a conflicting mixture of restraints, desires, and worries associated with or causing an unusual interest in, and experimentation with unconventional sexual activities.

*397\161\2*

In considering the status of the offender at the time of his offense, it is well to survey the evidence as to the prior existence of some type of severe neuroses or mental illness. Some might consider this an important mitigating circumstance. Since the present sample of offenses was based exclusively on offenders who, if they were incarcerated, were assigned to institutions that were primarily penal rather than mental, it is unlikely that any clear-cut psychotic cases are included. Sex offenders who were assigned to an institution for the criminally insane are not represented here. This screens out those who were declared legally insane at the time of the offense, or others who were adjudged so later while serving their prison term. The question then is how many offenses were committed by men who before the commission of the sex offense showed tendencies toward mental illness. We have used four criteria in establishing prior mental illness:

incarceration in a mental institution (not including brief detention for observation purposes or incarceration as a sexual psychopath).

Official diagnosis in the offender’s record. This must have been made by a person in a professional capacity, and must state at least that the offender was severely neurotic or psychotic. Such standard expressions as “confusion of sex role,” “latently homosexual,” or “a high degree of immaturity” were not considered as sufficient to classify the offender as mentally ill at the time of the offense.

Private treatment. This was considered only if there had been a minimum of three visits to a therapist.

Interviewer evaluation. This was based on such factors as degree of comprehension of reality, orientation, and coherence. An attempt was made to take into account that the condition or tendency might well have developed subsequent to incarceration.

When these criteria were applied to each of the 2,111 offenses on which there were adequate data, we find that in 97 offenses, or about 5 per cent, there was evidence of an impaired mental state previous to the offense, Multiple criteria from the four types of evidence used were found in only a quarter of the 97 cases singled out. This strongly suggests that some of the cases identified may be borderline ones, possibly not meriting the label given them.

Turning now to the question of how many individual offenders were responsible for these 97 offenses, we find a total of 71 different males involved, since 46 offenses fell into the category of multiple convictions of the same offender. Specifically, 51 males had committed one offense, 16 were convicted of two, and the remaining four accounted for either three or four apiece, bringing the total convictions for sex offenses by these offenders up to 97.

The varying degree to which these specified offenses were found in the 14 basic categories of offense types is shown in Figure 26.

While the incidences listed are none of them exceptionally high, they show a fair range, 11 percentage points, from 1 per cent in peeping offenses to 12 per cent for offenses in the incest vs. adults group. It is also evident that there was a comparatively greater degree of mental illness associated with certain kinds of offenses, especially the ones based on pedophilic acts. All four groups in this latter class fall well above the midpoint of the rank-order, standing in the second, third, fourth, and sixth places. In contrast, three of the four types of offenses vs. adults stand in the lower half of the rank-listing. Homosexual offenses tend toward the midpoint, with the exception of those vs. children, which stand high in order, in third place.

To summarize, mental difficulties previous to the offense behavior cannot be viewed as an explanation in any general sense, since they existed in a relatively small number of cases. The evidence suggests, however, that when such problems are found, they more frequently antedate the offenses that are usually considered as furthest from the norm, more specifically those against a male or female child under twelve years of age.

*359\161\2*

The proportion of total sexual outlet constituted by extramarital coitus with companions is ordinarily less than one tenth. Indeed, in only four groups did the proportions exceed this in any of the age-periods, and in two of these the percentages are 11 and 12 per cent.

General trends are difficult to discern and it is apparent that various groups responded differently to different factors. For instance, the prison group seems to carry over into marriage some premarital promiscuity and then gradually “settle down” to marital fidelity. On the other hand, the control-group individuals—rather restrained sexually before marriage—seem gradually to depend more and more upon extramarital coitus, the proportion of total outlet rising from 1 per cent in youth to 7 per cent in their fifties. Still others, such as the exhibitionists and the homosexual offenders vs. minors, maintain essentially uniform proportions throughout life. Some fluctuate inexplicably in response to what are probably fortuitous circumstances. Lastly, the incest offenders vs. minors and adults display increased proportions of extramarital orgasm as they reach the years (36-40 and 41-45) when their daughters attain the age required by our definitions.

The proportion of total outlet of married males derived from extramarital coitus with prostitutes is usually trivial; few groups exceed 1 per cent, and none exceed 3 prior to age fifty. Such coitus was quantitatively more important to the prison group and to the exhibitionists than to others. Since we know that exhibitionists prefer to exhibit to strange women rather than to their wives or female friends, this preference may account for a mild predilection for prostitutes (i.e., strangers). Concerning the prison group, one feels that their emphasis on prostitution is simply a by-product of their social milieu and style of life rather than any evidence of social adjustment or emotional status.

*321\161\2*

Among the married, the temporary resurgence of masturbation is not evident in the control and prison groups. It is clear only in some of the sex-offender groups—especially in the exhibitionists. There is no over-all explanation for this phenomenon. It does not presage a sex offense, it does not seem linked with marital dissolution, nor does it equate with the childbearing period.

The separated, divorced, or widowed men for whom we have data tended to find an increasing proportion of their total outlet in masturbation during the fourth or fifth decade of life but less thereafter. Whatever factors account for this they do not apply to all currently unmarried males: the premarital and the postmarital masturbatory increases are not generally synchronous nor do they coincide with the marital. The groups which the public would regard as sexually the most “normal,” the control and prison groups and the offenders vs. adults, show some fluctuation in the proportion of postmarital sexual outlet derived from masturbation, but the peak occurs in their forties. The other groups, i.e., all the sex offenders save the offenders vs. adults, have their peaks in their thirties or even before.

Marital status exerts a profound effect upon the proportion of total outlet obtained through masturbation. With marriage and the more routine availability of coitus, masturbation becomes, in most groups, relatively unimportant—generally accounting for less than 10 per cent of all orgasms. The only groups with larger proportions in the younger years of marriage are those known to have serious heterosexual problems: the exhibitionists and the homosexual offenders vs. adults. In the latter group between ages twenty-one and thirty masturbation accounts for from roughly one quarter to one third of their outlet.

Marriage almost obliterates masturbation in both the control and prison groups and in the heterosexual offenders vs. adults (depressing the proportions to less than 5 per cent as a rule). Moreover, in these groups masturbation never clearly resurges. In most of the other groups, however, marriage has a somewhat less violent effect and the proportions often increase. This resurgence, while it cannot be linked to an offense, we regard as a symptom of marital sexual difficulty and it is probably also indicative of general heterosexual problems. Some groups, particularly the incest offenders vs. minors and adults, appear essentially the same as the control groups until this resurgence appears to label them as sex offenders.

At this point we should announce that when one is considering individuals rather than groups, substantial amounts of masturbation by married men are not necessarily indicative of heterosexual difficulty or of an impending sex offense. The greater amount of masturbation may simply reflect unavoidable absences, the illness of a spouse, or pregnancy. In groups, however, such extenuating circumstances cannot be expected to play an important role, and large masturbatory proportions of total outlet must be construed as symptomatic of marital trouble or of inhibition regarding coitus.

After marriage has ended, the degree to which masturbation regains the predominance that it held in early premarital life varies markedly in our comparative groups. The question arises: Will the sexual behavior revert to the premarital status or, because of habits and preferences formed or reinforced during marriage, will it be essentially a continuation of the marital pattern?

The answer to this question is obscured by the fact that reality does not parallel the wish; much as an unmarried man might prefer coitus over masturbation, the former is frequently very difficult to obtain. Consequently, among the groups who masturbated least during marriage (the control and prison groups and the offenders vs. adults) we find that the proportions of total outlet comprised by masturbation in postmarital life fluctuate rather strongly according to what most men would term luck, and sometimes approach premarital levels, though never exceeding 25 per cent.

The groups whose members have difficulty in obtaining sexual partners—a difficulty represented by sexual activity with children— also derive very large proportions of their total postmarital sexual outlet from masturbation. The homosexual offenders vs. children have proportions ranging from 35 to 50 per cent, and their postmarital percentage essentially equals their premarital in one age-period. Similarly, the heterosexual offenders vs. children have large proportions (60 per cent, grading down with age to around a 35 per cent level) that often equal or surpass premarital figures. The exhibitionists, a third group with serious sociosexual problems, also show large masturbatory proportions of total outlet in postmarital Me, in one instance exceeding the premarital. The homosexual and heterosexual offenders vs. minors-minors being more available and of a socially more suitable age—never display postmarital percentages equaling the premarital. Those whose sexual targets were adult unrelated females (i.e., the control and prison groups and the offenders and aggressors vs. adults) display relatively small proportions of postmarital masturbatory outlet—always (with one dubious exception) below premarital levels.

*283\161\2*

As a group the exhibitionists do not manifest many salient traits, but those which do exist all point toward some deficiency or difficulty in heterosexual adjustment.

In childhood the exhibitionists did not socialize well with other boys and girls, although this does not seem to have adversely affected their sex play. In postpubertal life the signs of heterosexual difficulty are more numerous. .Masturbation played an important role among the married men. Premarital petting began rather belatedly and premarital coitus included much with prostitutes. Relatively few exhibitionists married, and among those who did marital coitus accounted for fewer of their orgasms than was true for most other sex offenders. In both extramarital and postmarital coitus the men again relied rather heavily on prostitutes, as they did before marriage, indicating some problem in adjusting to females.

Setting aside those whose offense was primarily the consequence of drunkenness or mental deficiency and concentrating on the repetitive exhibitionists, who comprise about half of all exhibitionists, one can make a number of useful generalizations. The exhibition stems from a truly compulsive urge which is usually triggered by some emotional stress. The sexual availability of wives or other females does not seem sufficient to prevent this urge, which certainly rests on a complex emotional rather than a simple physiological basis. The exposure is almost invariably to strangers and not to wives, friends, or acquaintances. There is the suggestion that the exhibitionist, despite what he says, may be avoiding exposure to females who might cooperate sexually and thereby put his masculinity to the test. In this connection it is worth noting that not infrequently he may expose himself to unsuitably young girls, which hints at feelings of inadequacy in relationships with adult females. The exposure of the penis, which is generally erect, is most commonly made outdoors at a distance ranging from two to many yards. The distance seems to vary with the aggressiveness of the exhibitionist, but exposure at very close range (within arm’s length) appears to be rare. While the great majority of exhibitionists do not resort to violence, a minority of perhaps one in ten have attempted or seriously contemplated rape.

The motivations of exhibition are, of course, not to be clearly defined by this study, but our impressions do agree with some psychiatric concepts. Certainly some exhibition is largely an affirmation of masculinity, a cry of “Look, here is proof I am a man!” This is the response of the insecure male who has suffered some ego-shattering sexual rejection or corrosive long-lime sexual stress. Also important is the element of sexual solicitation, which many exhibitionists consciously recognize although their hopes are almost never realized. Thirdly, and perhaps less common, is exhibition as an expression of hostility or sadism: a desire to frighten and shock. Very few of these people consciously feel such hostility, and on the whole the exhibitionists are to be pitied rather than feared.

*244\161\2*

Nongonococcal urethritis (NGU) is a urethral infection in men that is sexually transmitted and is not caused by gonorrhea. It can be caused by several organisms, including Chlamydia trachomatis (in 23-55% of men with NGU), Ureaplasma urealyticum (20-40%), and Trichomonas vaginalis (2-5%). It can also, rarely, be caused by the herpes simplex virus, as well as other bacteria or viruses. (See the sections on chlamydia infection, trichomonas infection, and herpes for more information.) Men who perform anal sex on partners may develop urethral infections from the bacteria that are normally found in stool. NGU, therefore, is not a specific “bug,” but rather a syndrome with several possible causes. Before many of the specific organisms that cause this infection were identified, it was also known as nonspecific urethritis.

HOW COMMON IS IT? NGU is the most common problem for which men seek help in sexually transmitted disease clinics. It is estimated that four to six million men in the United States are infected with NGU each year. Men of any age can become infected, although NGU is most often diagnosed in younger men (those in their teens to twenties) who are more sexually active and less likely to be following safer sex practices. A man can be infected and not know it.

*355\213\8*

An initial herpes infection can occur in the anal and rectal area, most often after having received anal sex. This infection usually causes rectal pain and discharge, which may be bloody, and it can also cause fever, muscle aches, and changes in bowel movements. Recurrences of outbreaks can occur in the rectal area. Although HSV outbreaks inside the rectum usually occur as a result of receptive anal intercourse, herpes outbreaks can occur around the anal area even in someone who has other STDs also cause sores in the never received anal sex, because the nerve that supplies that area also supplies the genital area.

Herpes infections can cause more serious symptoms. For example, genital herpes outbreaks can cause inflammation of the lining of the spinal cord, called meningitis. Meningitis caused by herpes is a type of viral meningitis that is different from the often life-threatening bacterial meningitis. Signs of this infection are a stiff neck and pain in the eyes when looking at light. Most people who have a first infection with genital herpes have some inflammation of the spinal fluid, since the virus is in a nerve, but only a small percentage develop symptoms from this inflammation. For a very few people, the only symptom of recurrent herpes outbreaks is viral meningitis. Meningitis from herpes infections seldom causes any permanent problems, but it may recur, either with or without subsequent outbreaks.

Oral herpes infections can cause inflammation of the tissues of the brain, called encephalitis. Signs of this infection are headache, fever, confusion, seizures, and neurological impairment, depending on which area of the brain is affected. Encephalitis can result in permanent neurological symptoms. However, considering how common oral herpes infections are, this is a very uncommon complication.

*262\213\8*

As already mentioned, the causative organisms of prostate infection may or may not be sexually transmitted. Oral, genital, or anal intercourse can cause infection with bacteria such as those responsible for gonorrhea and chlamydia if a partner is infected, whether or not he or she is symptomatic. Performing anal sex on a partner also increases the risk of infection of the prostate with the bacteria commonly found in stool. Condoms—if they are used consistently and correctly and they do not leak or break—will prevent the transmission of these bacteria.

Prostate infections that are older and who have some predisposing structural cause, such as enlargement of the prostate. Common misconceptions are that prostate infection is caused by sitting too long, by not having sex frequently enough, or by various dietary problems. All of these statements are not true.

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If your partner is uncomfortable or is not ready to talk about sex, let him or her know that you understand that these are difficult topics to discuss, and that whenever he or she is ready to talk about them, you are ready to talk, too. But let your partner know that you don’t want to have sex until you have had this discussion.

When you and your partner do have the discussion, keep in mind that what you want is a dialogue, in which both of you can express your feelings on these topics. Blanket or judgmental statements—such as “Everyone who has sex without a condom is stupid”—rarely lead to an open discussion. Try to be honest about your own thoughts and goals. Don’t say things to impress your partner. Use “I” statements (such as “I would like to use a condom”); they allow you to express your feelings openly and clearly. Then you can ask your partner about his or her feelings, using open-ended questions such as “What are your thoughts?” If you are having this conversation, the odds are that both you and your partner have been thinking about these issues and want to find out specific information about each other. Answering the questions listed here will provide the information that you will want to have before beginning a new sexual relationship. It is important to be honest. Intentionally misleading your partner will only weaken the foundation upon which your relationship is based.

Rather than reading the questions off like a laundry list, or interrogating your partner in a way that makes him or her uncomfortable, you may want to cover these topics in the course of your conversation. However you and your partner go about discussing these subjects, you should plan to get answers to the following questions:

1. How many sexual partners have you had in the past?

2. Have you had any partners of the same sex?

3. Have you ever had unprotected sex with a partner?

4. Have you ever used injection drugs? Did you ever share needles?

5. Have you ever received a transfusion of blood or blood products? (The U.S. blood supply began to be screened for HIV in 1985; the risk of acquiring HIV infection from blood transfused since 1985 is very low.)

6. Have you ever been tested for sexually transmitted infections?

*77\213\8*

There’s not a lot of good information on this subject, but some studies have indicated that farmers and mechanics may have a higher risk of prostate cancer. It’s hard to know what to do with information from such studies, however; it’s very difficult to separate what people do from who they are—their family history, their diet and habits. For example, do farmers and mechanics have more fat in their diets than others? Do they smoke more? One case-control study found that 75 percent of 40 patients with prostate cancer had a history of farming compared with 37.5 percent of control patients with BPH. (On the other hand, it could be argued that these older men were products of a generation that was much more agrarian. Who knows?)

Other studies have indicated that cadmium, a trace mineral present in cigarette smoke and alkaline batteries, may have something to do with prostate cancer. Men who are welders or who work in electroplating, over time, get exposed to high levels of cadmium; these studies suggest that cadmium exposure marginally increases a man’s risk of developing prostate cancer. One explanation may be that cadmium somehow interferes with zinc, a necessary element in many of the body’s activities—and men with prostate cancer have been found to have lower levels of zinc in their prostates than other men.

What does it all mean? If you’re a farmer, or a mechanic, newspaper worker, plumber, welder, or worker in a rubber-producing factory (all of these have been suggested, without much proof, as occupations that raise a man’s risk of getting prostate cancer), don’t be alarmed. There’s no evidence to indicate that you should.

*30\201\8*