After she had talked further to the doctor, she mentioned how she had been tempted to make the disclosure the previous year when being counselled by him about sterilization, but felt she could not inflict this on her husband who was present. She had also contemplated disclosure at other appointments but had either been prevented by a very unpleasant lump in the throat or by being inhibited by the presence of her young children. Although distressed she said she felt considerably unburdened after the disclosure. The GP congratulated her on her courage in talking to him that day. After she had gone out he looked at the number of contacts they had had while she was holding onto her secret. He had personally seen her with an appointment for herself seven times and had visited her at home twice after the birth of one of her children. It had taken nine contacts for trust to develop and the time to be ripe for the disclosure.

*340/197/1*

An immediate agreement that this can be done defuses the aggression and determination not to be talked into continuing with what seems to be the cause of difficulties. Then the situation can be further explored to find out what is behind the anxiety.

Mrs J. had her hair combed into an immaculate French pleat at the back and was wearing a smart business suit. She put her briefcase between herself and the doctor. She wanted to be sterilized and come off the Pill. ‘That man doctor said I was far too young and would change my mind?’ She harrangued the doctor about ‘men’ and ‘patronizing doctors’ until this woman doctor felt uncomfortable not agreeing with her. The doctor shuffled the notes around and managed to interject, ‘Some doctors are like that but Dr M. is usually quite sensitive and understanding.’ Mrs J. stopped her complaints and glared at the doctor accusingly. ‘Anyway,’ the doctor continued, ‘tell me about why you would like to be sterilized.’ Mrs J. explained that she was 26 had a responsible executive career and did not want any children. She did not want to go on taking contraceptive pills, she always felt nauseous when she restarted each pack and was sure they could not be doing her body chemistry any good. Other methods? They were quite disgusting or barbaric or just unreliable, so she had decided on sterilization. ‘What about your partner?’ the doctor queried. ‘My husband,’ she emphasized, ‘understands that my career must come first.’ There was an expression of contempt on her face. The doctor, attempting to understand the contempt, tried out: ‘It sounds to me as if you wish he would disagree.’ Mrs J. was less strident, ‘Oh, he never stands up for himself – he likes a quiet life.’ There was a long pause. ‘He can’t even get an erection half the time now,’ she said, looking more vulnerable. ‘He offered to have a vasectomy, but I thought it might make the erection problem worse.’ With the loss of her defensive hostility, the doctor was able to talk with Mrs J. about her relationship. Her need always to be seen to be in charge at work and how difficult it was to switch off when she was at home. How she wanted him to be assertive (and erect). She did not ask about sterilization again, had a routine check and renewal of the Pill and left, promising to return if things were not improving.

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From another point of view, many 35-year-old women would be horrified to be labelled ‘an older woman’. With increasing longevity and health, women continue to feel young well into their 60s and beyond. Many women continue to have regular periods beyond 50 years of age. The increased acceptance of sexuality as a rich part of life, and the desire to enjoy this part of themselves without fear of pregnancy applies as much to older women as to those who are younger.

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Other authors have sought to provide a catalogue of the practices and customs of all the different cultural groups found in the UK today. These are tabulated against attitudes to different contraceptive practices as a sort of ready-reckoner for the health worker. This approach is limited in its relevance to what actually goes on in the clinic or surgery, and quickly goes out of date. The Bengali people who can come to live in Britain are not identical culturally to those in Bangladesh. Both communities are changing, and the different generations will readily demonstrate the lack of uniformity in one ethnic group.

*225/197/1*

It is almost inevitable that in a clinical diagnostic report to a court personality characteristics are described in their negative rather than positive aspects. There is always the dangerous probability of misinterpretation: the happy extrovert may be labeled manic and irresponsible while the quiet reserved individual may be termed despondent and withdrawn. This brings up a contention sometimes made and never adequately rebutted that certain traits such as passivity and anxiety may be by-products of confinement rather than characteristics of the individual.

In reviewing the written records of the clinicians we compiled a list of the more commonly mentioned traits, generally in adjective form. Many of these come from the vocabulary of psychoanalysis (e.g., oral type, narcissistic), others stem from psychiatry (e.g., schizoid, compulsive), and still others are borrowings from the lay vocabulary (e.g., anxious, unstable). Inasmuch as the terms were applied with varying frequency to the six groups of sexual psychopaths under consideration, there is no merit in giving the adjectives applied to sexual psychopaths as a whole except to say that no one descriptive term was applied to as many as half of the men. The most popular word, “neurotic,” was used in 45 per cent of the cases; the second most popular (38 per cent) was “immature.”

Curiously enough, while almost all the clinicians whom we interviewed rejected the concept of sexual psychopathy as a clinical entity, about half of them were equally resistant to the idea of categorizing the men according to their offenses. Their attitudes might be simply summed up as follows: the men labeled sexual psychopaths are sick, their offenses are just one of many symptoms of their sickness, and the nature of the offense is largely an artifact of external circumstances and is often almost fortuitous. Those who subscribed to this philosophy tended to have heterogeneous therapy groups of various offender types. Other clinicians differentiated pedophiles, exhibitionists, homosexual offenders, etc., and often tried to keep their therapy groups homogeneous. These clinicians were willing to make generalizations concerning offender types, and it is interesting to note that their generalizations did not always match the frequency with which certain descriptive words appeared in the written reports. Such discrepancy is to be expected since the clinicians we interviewed constituted only a minority of the authors of the reports. Moreover, as we know only too well, clinical impressions can frequently be seriously in error.

An examination of the written reports and the words used to describe the six varieties of sexual psychopaths under consideration, shows that some groups not only received certain labels more consistently than other groups, but got more than their fair share of verbiage.

The sexual psychopaths who were offenders vs. children were described with great brevity, and the description does not leave a coherent image in the reader’s mind. They had the largest proportion labeled latently homosexual or as having homosexual tendencies (22 per cent). They also ranked highest in being termed inadequate (22 per cent) and depressed (33 per cent). There was much clinical interest in whether the patients viewed women as domineering, oppressive figures (the stock phrase was “the patient views women as castrating”). This view was allegedly held by a large proportion (35 per cent, the second largest proportion recorded) of the offenders vs. children. It is evident that the clinicians did not regard these men as a clearly defined group.

In contrast, the sexual psychopaths who were aggressors vs. adults received much description and held distinctive rank with regard to many labels. They ranked first in the following: psychopathic (44 per cent), schizoid (31 per cent), paranoid (12 per cent), passive-aggressive (12 per cent), inferiority feelings (12 per cent), aggressive (44 per cent), oral type (19 per cent), and hostile (12 per cent). Here we have a clear picture of disturbed and aggressive persons. They ranked lowest in the labels of passive-dependent (6 per cent), anxiety (12 per cent), viewing females as castrating (12 per cent), and narcissism (0 per cent).

The sexual psychopaths who were incest offenders vs. children ranked first as being passive-dependent (15 per cent), psychopathic (44 per cent), immature (52 per cent), having castration fears (15 per cent), narcissistic (11 per cent), and sadistic (11 per cent). They ranked lowest only for the term schizoid. This is not a too sharply focused picture, psychopathy and immaturity being the major criteria, and neither of them are well-defined words.

The sexual psychopaths who were homosexual offenders vs. children ranked first or last in relatively few respects. They had the largest proportions of persons called unstable (20 per cent), regressed (16 per cent), and hostile (12 per cent). They had no individuals termed paranoid, obsessive, passive-aggressive, and oral type, nor did any of them have inferiority feelings or castration fears.

The sexual psychopaths who were homosexual offenders vs. minors were characterized as anxious (41 per cent), sociopathic (28 per cent), and feminine (45 per cent), ranking first in these three traits. They ranked last in paranoid tendencies, compulsivity, instability, depression, regression, hostility, and aggressiveness. One is left with the picture of a nonaggressivc, rather emotionally well-balanced group of men whose main difficulty lay in their choice of sexual object (sociopathic ) and who were disturbed over their conviction and confinement (anxious).

Lastly, the exhibitionists ranked first in the terms neurotic (74 per cent), compulsive (59 per cent), obsessive (37 per cent), inadequate (22 per cent), viewing females as castrating (44 per cent), immature (52 per cent), and passive-dependent (15 per cent). On the other hand, they were least often labeled psychopathic or sociopathic.

From an examination of these collections of descriptive words it is clear that despite the assertions of some clinicians there is a consensus that certain personality traits are connected with certain offenses. Thus the aggressors vs. adults rank high in terms concerning aggression. Similarly, the words used to describe the exhibitionists predictably group around neurosis, obsession, and compulsivity.

A cynic might say that these are post-factum diagnoses dependent upon the clinicians’ knowledge of the offense, but this does not seem to be true. Note, for example, the differences between the descriptions of the homosexual offenders vs. children and the homsexual offenders vs. adults, and also that both homosexual groups were not heavily weighted with the labels usually applied to homosexuals, such as references to fixation at infantile levels, Oedipus conflicts, and castration fears.

It is unfortunate that we do not have a tabulation of the descriptive terms used for the offenders who were not judged sexual psychopaths. This omission is no oversight on our part; it is due primarily to a paucity of data resulting from the fact that the majority of men were not subjected to sexual psychopathy examination. While the psychologists and other clinicians working in the prisons did make some descriptive comments about men convicted of the same offenses, we hesitated to compare these comments with the sexual psychopath data, for in doing so we would not only be comparing sexual psychopaths with other offenders, but also comparing the clinicians of the Department of Mental Health with those of the Department of Correction and thereby introducing yet another uncontrolled variable.

*401\161\2*

More of the outdoor offenses were urban than rural in location. This is undoubtedly in part an artifact of the sample selection, but it also reflects the less likelihood of walkers roaming far from their home bases. This is especially marked in the categories of heterosexual offenses against children and the aggression offenses against adults. Here the urban-rural ratio turns out to be more than 2 to 1.

*363\161\2*

This, however, is not the only peculiarity of this measurement. Certain groups which previously appeared relatively disinterested in homosexuality are seen to have incongruously high frequencies. For example, the heterosexual offenders vs. adults, in whom the incidence of homosexuality is low, have a moderate rather than low-average frequency of activity. Such incongruity simply means that the group contains a minority of very active individuals who are more strongly homosexual.

Turning to other measures of frequency, the median and mean frequencies of homosexual activity resulting in orgasm calculated for five-year age-periods, one finds that these calculations must be confined to the single individuals since too few married or postmarital males had homosexual activity while in that marital status. Even among the single men there are four groups with an insufficient number of members experienced in homosexual behavior to warrant frequency calculations —the aggressors vs. children and minors and two incest-offender groups. In terms of average (median) frequency among those with homosexual activity, we find the three homosexual-offender groups are at the top of the rank-order for age-period puberty-15, with orgasm about once every two weeks. They are followed by the peepers and the three heterosexual-offender groups with frequencies of between 10 and 19 orgasms a year. All other groups range from 5 to 8 annually. In age-period 16-20 the three homosexual-offender groups are still together, but the offenders vs. adults display considerably higher frequencies than do the other two. The remaining groups range from 3 to 10 orgasms a year. In age-period 21-25 this basic pattern remains, except that the prison group now slightly exceeds the homosexual offenders vs. children in frequency. The same situation prevails in age-period 26-30, alter which sample size precludes further comparisons.

Speaking generally, the active median frequency of homosexual activity resulting in orgasm is often greater before twenty than it is in the years from twenty-one to twenty-five; this seems due to adolescent experimentation and the difficulties society places in the way of young males seeking heterosexual coitus. Subsequently, however, for both control groups and the homosexual offenders there seems to be an increase in frequency with age. The active mean frequencies present much the same picture.

*325\161\2*

In the tabulation of ages at the time of the first nocturnal emission the control group is once again distinctive with the youngest median age recorded (15.2 years). The homosexual offenders vs. adults share this rank. Here again we find the two best educated of our comparative groups statistically equal. This is not unexpected, since in our 1948 volume we noted that nocturnal emissions began earlier among males of the college level than among males of lower educational levels. Parenthetically it should be added that age at puberty is not a common explanatory factor in this similarity between the homosexual offenders vs. adults and the control group. However, the time gap between the age at puberty and die age when first nocturnal emission occurred is smaller among those who reach puberty early and greater among those whose puberty is belated. Aside from the above, this tabulation reveals little: the majority of medians fall between the sixteenth and seventeenth birthdays.

There is no significant correlation between the percentages of the various groups who had experienced nocturnal emissions and die type of offense. The groups constituting the tripartite types are scattered, and there is no tendency for pedophiles to concentrate at any point. However, as the tables show, relatively large proportions of both the control and prison groups had orgasms during sleep.

Since the above “ever-never” type of listing is influenced by the average age of each group, despite the fact that the youngest group (the peepers), and the oldest (the incest offenders vs. adults), are contiguous in the rank-order, we should turn to incidence calculations in which age is controlled. In accumulative incidence the control group almost always tops the list. By age twenty, for instance, the figure for the control group is 83 per cent, while all other groups range from 58 to 80 per cent. The prison group also usually ranks high, often being in third place. Aside from this, accumulative incidence tells us nothing new.

Age-specific incidence, the percentage experiencing orgasm in sleep within a given age-period, again emphasizes the comparative importance of this outlet for the unmarried control group, which exhibits the largest percentages in nearly every age-period up to age thirty-five. Beginning in the puberty—15 age-period with 55 per cent, about three quarters to four fifths of the controls experienced nocturnal orgasms in every subsequent age-period up to age thirty-five. Thereafter they drop to third place. Among the married men the controls have the largest percentages in three of six age-periods, and rank second or third in the other three, from one half to three fifths of their members experiencing nocturnal emissions in any age-period up to age forty. Among the separated, divorced, or widowed, the percentages are larger than among the married, but they do not rebound to the levels set by the single males. The controls again lead with percentages that decline from the 70s to the 40s by the end of the fifth decade of life. The majority of the other groups begin with percentages in the 50s and 60s, but do not decline so rapidly—in consequence their percentages often equal or nearly equal those of the control group in later life.

Aside from this pronounced separation of the controls from all other groups, little can be said regarding age-specific incidence. No particular clusterings or trends are observed, although contiguous pairs of tripartite groups do sometimes occur. It is, however, worth remarking that marriage does not reduce the incidence of orgasm in sleep as much as it reduces masturbation, which suggests that the decrease in masturbation is in part voluntary rather than a simple displacement phenomenon.

*287\161\2*

The obscene telephone caller is more than just an offensive nuisance, but this is because his victims interpret his behavior as a threat. Even a sexually experienced and emotionally stable woman is uneasy when she realizes that she. is an object of sexual interest to someone whom she regards as mentally unbalanced. There is always the thought: What if he comes around? Since the majority of females listed in a directory are unmarried, they are most often the target of the obscene telephone caller and, lacking the protection of a husband, they are particularly apt to be alarmed. Furthermore, a fair number of the unmarried owe their marital status to an aversion toward or disinterest in sex and hence the telephoned vocabulary is deeply disturbing to them.

An examination of our six cases reveals some interesting consistencies. While most sex offenders came from broken homes, only one of these men did. Furthermore, they seem to have gotten along with their parents reasonably well and were quite adequately supplied with siblings (only one was an only child). Similarly there is nothing unusual about their relations with their peers: they usually had enough playmates when young, and friends and companions later.

Moreover, five of the six had quite adequate (and in two cases abundant) heterosexual coital activity, at least from the viewpoint of frequency and number of partners. The sixth, the only one who did not have coitus, was somewhat feeble-minded. However, lie petted and did not complain about his lack of coitus.

Not only were the heterosexual lives of these males quantitatively adequate, but in addition five of the six had had some homosexual experience after puberty. This behavior was sporadic in four cases, and in the fifth, where it had been regular, it had been long discontinued. In brief, while a homosexual element is a part of these men’s histories it did not loom large in terms of frequency.

Their sociosexual activities combined with their nocturnal emissions and a rather substantial rate of masturbation give these men frequencies of total outlet well above-average. Three of the six had for some years in their lives averaged more than an orgasm a day; two of the remaining three had averaged over 5 orgasms a week; and the remaining man averaged between 2 and 3 a week.

This high total outlet suggests that these may be individuals who cannot, or feel they cannot, do without orgasm to the extent that most other males can. This is not to bring up the old “sex fiend” theory, but they may be physiologically or, more likely, psychologically driven to activity and unable to delay their need for sexual gratification. Telephoning is a readily available and fairly safe means of sexual stimulation and gratification. This idea of drive is buttressed by evidence of compulsiveness: these men continued their telephoning or other obscene communication after having been arrested for such behavior on one or more prior occasions. Their disregard of foreseeable consequences and their failure to learn from experience are the same as the exhibitionists’. It is of interest that three of the six “obscene telephoners” had also been convicted of exhibition.

The compulsiveness was such that alcohol was not necessary to overcome inhibitions and scruples: only one male usually became intoxicated before telephoning. Similarly, drugs played no part.

In terms of previous criminality the six men are divided sharply into two equal groups. Three of the men had no convictions other than for obscene communication; they evinced no other asocial or antisocial tendencies. Their problems tended to be more internal than external: one male was an unstable youth disfigured facially, one male was mentally very dull, and the third had difficulties exacerbated by drinking. The other three males present a different picture: one was a twenty-three-year-old with a history of burglary, exhibition, homosexual prostitution, use of marijuana, and some tendency toward violence; another had had five marriages, convictions for theft, exhibition, and forgery, and was close to becoming alcoholic; the third had over a dozen convictions stemming from obscene communications, showing pornography, exhibition, and touching females without their permission.

One is left with the impression that obscene telephone communication is not a discrete behavioral and psychological entity, as are some sex offenses, but is simply one more instance of a pathological development of an interest common to most males—a symptom of some sexual and emotional difficulty. This difficulty may be related to exhibition since half of the males involved were also exhibitionists; moreover, obscene communication may be looked upon as a sort of verbal exhibition. The true exhibitionist seeks to cause a strong emotional reaction in his feminine audience and/or arouse the females sexually; these are aims common to the user of obscene communication. One uses his taboo anatomy, the other his taboo vocabulary. Note also that self-masturbation frequently accompanies both.

*249\161\2*

Pelvic inflammatory disease (PID) is a bacterial infection of the pelvic organs in women that can involve the uterus (in which case the infection is called endometritis), the Fallopian tubes [salpingitis), the ovaries [ovarian abscess), or the peritoneum (the lining of tissue around the pelvic organs,- pelvic peritonitis). One, several, or all of these organs can be affected. PID is usually caused by sexually transmitted bacteria such as gonorrhea and chlamydia, but it can be caused by other bacteria as well. It is the most serious infection of the genital area in women.

HOW COMMON IS IT?

It is estimated that about one million women develop PID each year, but this is likely to be an underestimate since in many parts of the country PID is not reportable to the local health department. Three-quarters of the women infected are younger than twenty-five, but women of any age can be infected.

About 85 percent of cases of PID are caused by sexually transmitted bacteria; a woman who has unprotected genital intercourse with a male partner infected with PID-causing bacteria is at high risk for becoming infected. The sexually transmitted bacteria break down the defenses in the cervix that normally prevent vaginal bacteria from moving up into the pelvic organs; thus they allow these bacteria to contribute to the infection.

The other 15 percent of cases of PID are caused by gynecological procedures that mechanically open the cervix and allow the vaginal bacteria to rise into the pelvic organs and cause infection. Women who have an invasive gynecological procedure—such as an abortion, the insertion of an intrauterine device IUD , or hysterosalpmgography (an X-ray study to examine the Fallopian tubes and uterus by means of the injection of dye into these structures)—are at increased risk for developing PID. In addition, women who use IUDs as a birth control method run a higher risk for developing PID if exposed to sexually transmitted infections. Women who douche are also in the high-risk category, possibly because douching pushes vaginal bacteria higher up into the genital tract. Women who have had PID in the past are at increased risk of having it again, because scarring from the infection makes them more vulnerable.

Men, obviously, do not get PID, but they can be infected with the bacteria that cause it.

*359\213\8*