Psychosexual skills are not a watered down form of psychotherapy, although psychodynamic ideas are used in the training and practice. The doctor develops a focused way of working in an important area of the patient’s emotional life. Those in training will probably want to arrange times when they can give their patients a few longer appointments, but they are not encouraged to engage in extended therapy. Indeed, the doctor/patient relationship where the doctor becomes over-involved with the patient is worthy of study, and may be revealing a particular problem of dependency for that patient. The aim of training is not to suggest that doctors should provide time-consuming long-term support, which may be more appropriately provided by others, but that they should learn to use specific skills within the practice of their normal work. The general practice and clinic settings, and particularly the family planning consultation, provide patients with repeated opportunities to visit doctors about routine matters, and they can choose the moment that is appropriate for them to discuss their inner pains.

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It has been shown that positioning chairs in the consulting room so that the doctor and patient face each other across the corner of the desk encourages more verbal interaction than when doctor and patient are on opposite sides of the desk (Pietroni, 1976). Also, it has been estimated that two-thirds of the communication which goes on in a two-person conversation is nonverbal and only one-third verbal.

The beginning of the consultation has proved to be of great interest and of vital importance. Clearly, to get off on the wrong footing may ruin the whole consultation. Neighbour (1987) has analysed this phase in considerable detail. ‘Curtain raisers’ are little throw-away lines such as, ‘You’ll be getting fed up with me’ which may be missed as the patient enters. The consultation has begun at this stage and interventions from now on can disturb the flow of the consultation. Lines such as ‘You are busy today, doctor’ (really meaning ‘you have kept me waiting 40 minutes’) may even provoke some anger in the doctor if pressure of work that day is beyond his or her control.

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This patient had not needed any ‘therapy’; she had the answers within herself but needed a skilful listener to enable her to make the transition from ‘obedient nonsexual child’ to ‘independent sexual adult’. By recognizing that the doctor/patient relationship started as teacher/pupil and by refusing to instruct her, the doctor helped Miss A. to take a more adult role, accept the problem as her own, understand the difficulties and see that she could solve it herself. The skill here lies not in what the doctor did but what she restrained herself from doing in response to the initial doctor/patient interaction.Doctors and nurses unskilled in picking up clues about hidden problems may find some contraceptive consultations baffling and frustrating. The patients who can never find a satisfactory method; this Pill made them sick, that one gave them headaches, the coil made them bleed, they had cystitis with the diaphragm, and there is no chance the partner will use a condom. These patients manage to outmanoeuvre and defeat their advisers. Only by understanding that ‘nothing is right with contraception’ may be a synonym for ‘nothing is right with my sexual life’ can this be untangled (Rogers, 1989). Sometimes specific complaints with contraception can turn out to have quite different causes.

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For many couples with a disability, as for able-bodied couples, the question of the timing of a sterilization is paramount. Often, if the doctor can help them to find a method for the next year or two, the situation can then be reviewed. Not only will the couple then be older, but other practical and emotional changes may have taken place which can profoundly effect their decision.

The care of individuals with mental disability has changed a great deal in recent years, and there is now a greater understanding of their needs and less fear of their condition (Greengross, 1976). However, instances are still seen where control of fertility was considered a priority which tended to over-ride other emotional needs of the patient.

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After a time practitioners may feel comfortable with their attitudes in theory, but maintaining them in practice is not so easy. It would be simpler if consultations were clearly confined to one subject such as contraception, but this is rarely so. The social concerns of recent immigrants overlap with their medical needs. The doctor/patient relationship is often conducted in the context of the doctor/family relationships. Doctors may be distracted by the need to look for opportunistic surveillance of young children who attend with their parents, as well as trying to support the families’ social needs, especially housing. The problems of overcrowding will lead naturally to a discussion of contraceptive needs, but it is important not to let one’s anxiety about uncontrolled fertility undermine the relationship of trust by appearing to blame the patient for her fertility. Dealing with so many issues and patients in one consultation can be very wearing, and it would be surprising if the practitioner never felt under strain, with a sense of burning out, when dealing with such needy families. Poor coping mechanisms lead to doctors using the issue of culture as a reason for not being effective, and lowering their standards. The support of colleagues is essential both emotionally and as a context for looking at ways of making practical changes that can help.

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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.

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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.

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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.

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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.

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