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?

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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*

H-Y antigen

The Y chromosome programs the differentiation of the undifferentiated cells of the primitive gonads into testes, beginning at around the sixth week of gestation. Differentiation of the undifferentiated gonads into ovaries does not begin until the twelfth week and requires the presence of two X chromosomes and no Y.

The Y chromosome programs the undifferentiated gonads toward testicular development via a plasma membrane protein, the Y-linked histocompatibility (H-Y) antigen. Exactly how the undifferentiated gonads in XX individuals are programed into ovaries is not clear. Ohno suggests the possibility of an ovarian-organizing antigen similar to that of the H-Y antigen. This ovarian-organizing antigen has not yet been identified.

Having programed the differentiation of the gonads, the sex chromosomes have no other known direct influence on subsequent sexual behavior and psychosexual (gender identity/ role) differentiation. The program of gender identity/role differentiation and development is now carried forward by the presence or absence of secretions of the newly differentiated fetal testes. Without the secretions of the testes, morphologic differentiation is female.

Adam-eve principle

Prenatally, the program of gender identity/ role is carried forward specifically by the determinants of masculine morphologic differentiation, namely, mullerian inhibiting substance and androgen, secreted by the testes. Present knowledge of embryology indicates that fetal ovarian hormones are not essential to female morphologic differentiation. Whether or not maternal and placental hormones are essential is not known. Nature is predisposed first to make a female and only with the addition of testicular secretions does it make a male. The embryological fact that nature’s preference is female is epitomized as the Eve principle. The fact that something must be added to make a male is epitomized as the Adam principle.

*2/187/5*

Women’s HealthAs already mentioned, it may not always be obvious to the ‘spreader’ of this bug that they are putting their sexual partner at risk. However, having a history of coldsores, on the face or the bottom, should be a reason for being a bit more cautious. Avoiding sexual contact when there is an active, obvious coldsore—no matter where it is, or how small and insignificant it seems—is very important, because this is the time at which most of the virus particles are shed.

Condoms may help to protect couples to some extent, for example if one partner has a history of genital herpes, but no active lesions. However, they may not give adequate protection if there is an obvious sore which will be shedding virus particles, and should not be relied upon in that particular instance.

Pregnancy. One of the concerns many of my newly diagnosed herpes patients express is about childbirth. They have heard that if you have ever had genital herpes you are automatically a candidate for a caesarian section (operative) delivery. While this may have been the case in the past, the tendency these days is for the decision about the mode of delivery (‘normal’—meaning vaginal—or operative) to be made closer to the actual due date. It is important for a woman ‘.o tell the practitioner she is attending for her pregnancy if she has had herpes in the past, or if her sexual partner has. It is possible to check for evidence of virus shedding or sores in late pregnancy. A baby passing through an infected vagina runs a small risk (about 10 per cent for a recurrent attack) of becoming infected. However, many women are likely to have no obvious virus shedding at the time of delivery, and a vaginal delivery is usually a safe option for mother and baby. Herpes does not affect a person’s ability to get pregnant.

*77\52\4*

Weekend warriors watch out! If you are male, getting on a bit, have a sedentary job but like occasional sport, you are a prime candidate for a debilitating and highly irritating injury. Without warning you could do in the largest and most vulnerable tendon in your body -your Achilles. It is estimated that one in 20 men past the age of 40 will either strain or tear this tendon at some time.

The Achilles stretches from the middle of the calf to the heel, and as sections of it are poorly supplied with blood, it is easily injured. While younger men who exercise daily may overuse their Achilles, making it inflamed and tender, older men who exercise intermittently tend to do far more damage. With a sudden movement, rapid acceleration, a jump or a twist, they can rupture the tendon. Bolting from the base line to take a net shot could see them off the tennis court for a year with a torn Achilles. Some men actually hear a snap or a pop as it tears and experience acute pain. They say it is like being hit hard from behind. Although the pain decreases rapidly, walking on the injured leg is usually not possible.

Men over 40 should be fit for their sport rather than using their sport to get fit. With care, the Achilles can be prepared for exertion. The current wisdom is that exercise should be preceded by stretching and a warm-up. Most importantly it should end with another stretch, followed by a cool-down. Training should be increased gradually, and at the very first sign of discomfort, activity should be stopped and help sought.

The Achilles degenerates with age, but most men don’t notice. A large recent study of ruptures showed that in all cases there had been degeneration.

Middle-aged men should also read the fine print before they take a course of antibiotics. One class of these drugs can actually cause tendon damage, particularly to the Achilles. Fluoroquinolone is an antibiotic usually kept in reserve and used only when the more common antibiotics fail to work. This drug has a direct effect on the collagen in tendons and can weaken them within 6 hours of the first tablet being taken. Well over 200 cases of fluoroquinolone-induced tendonitis have been reported in the world literature.

This drug is also used to treat prostatitis, an often-intractable inflammation of the prostate that can drive men demented. Those who take fluoroquinolone for their prostate should take care to protect their Achilles and not exercise unwisely while on the course of antibiotics.

*118\105\2*

It is well known that long-term alcohol abuse can affect higher-order functioning of the brain. It can impair memory and the ability to plan ahead. Usually, this catches up with men in their 50s and 60s.

One of the first symptoms is a dissociation between what they say and what they do. Affected men can recite rules but have trouble acting on them. It’s not deliberate: they just can’t. They know what is required, but they don’t put it into practice and they can’t see that they are not doing so.

One senior executive with a history of heavy drinking recently bowed to pressure from colleagues and consulted a neuropsychologist. He had excellent social skills, had obviously been very bright in the past and could hold a wonderful conversation. But although he was perfectly charming, he had a very poor memory. The doctor would tell him something, and when he raised it a few minutes later, it was as if the executive had never heard the information before.

CPs often do not pick up such impairments during standard check-ups. They do many basic tests but are not equipped to assess higher-order brain function. Men like this executive often sail through routine check-ups because their social skills disguise their symptoms.

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