Noticing the emotional content, or the lack of it, at the time of a physical genital examination is a psychosomatic skill. When the details of the examination are studied they always provide some information about the patient, even if it is only to do with the degree of control of detachment. But it is not a prying examination on the part of the doctor to discover secrets that the patient wishes to hide. Rather it is an enabling moment when the patient may be able to get in touch with unacknowledged feelings. Often it is the moment when some unspoken anxiety can be revealed, and there is an opportunity for the doctor and patient together to explore her ideas and fantasies about the body.

Once the patient had been helped to put these ideas into words, it was not difficult to help her to confront her fantasy with the reality of a intact vagina by encouraging her to feel inside and to contract her muscles round her finger.

*372/197/1*

One of the classic texts has been that of Pendleton, Schofield, Tate et al. (1984), which for the first time emphasized the importance of taking into account the patient’s ideas, concerns and expectations and involving the patient in the process of understanding the problem and working out solutions. Without wishing in any way to undermine the achievement of this work, doctors may find their model rather theoretical and difficult to hold in mind while consulting.

Two further workers have refined the comprehensive Oxford model and, arguably, made it more accessible and immediate. Neighbour (1987) condensed the seven tasks of the consultation into five. His innovative book raised for the first time the intuitive element in the way a consultation is conducted. His illustrations from analysis of videotapes are delightful and can fundamentally change one’s approach to consulting. Finally, Middleton (1989) produced the most recent paper which is simplicity itself. Communication skills are used to reconcile the respective agendas of both doctor and patient into a jointly negotiated plan.

Distilling what this author considers to be the best of these various models, a scheme has been made which is helpful for consultations which have minimal illness content and can be used by the doctor during a consultation. The headings in this chapter refer back to this scheme.

*334/197/1*

(INTRODUCTION)

Because sexual activity is implicitly indicated by the attendance for birth control advice, it is easier for patients to broach the subject with the nurse or doctor (Tunnadine, 1992). Some patients find this easy, others need prompting or require sensitivity to the hesitation or hints. Asking patients routinely, ‘Have you any sexual difficulty?’ may occasionally be productive but is more likely to elicit a negative response. Such an answer makes it less easy for patients to complain to their advisers at a later date when rapport between them has been better established. Open-ended enquiries such as, ‘Any problems?’ or ‘How are you getting on?’ are more likely to enable patients tentatively to sound out doctors and nurses for their response. A reply of, ‘No problems really’ may need the prompt, ‘Does that mean no problems, or a problem that you are not sure whether to mention?’ Overtures such as, ‘Is it normal for a woman not to have an orgasm?’ need to be met by a receptive response. A closed reply like, ‘It always takes a while to get the timing right in any relationship’ prevents any further exploration of what the complainant means by her enquiry. Although the way the question was put suggests a problem with satisfaction within the sexual act, the real reason may be a lack of desire, a failure of response or a combination of all three. Without an enquiring look or a ‘Tell me a bit more’, the adviser has no way of understanding the problem being presented. By assuming knowledge, thinking that understanding is present, reassurance or information may be given completely inappropriately. Often, just by telling the doctor or nurse about the problem, patients can see for themselves what causes the difficulty and what they can do about it.

*295/197/1*

Long and convoluted counselling with this couple was necessary in order to establish the root cause of the hurtful actions and anger present in both partners. They were seen both singly and together. The fantasy that all sexuality is lost at sterilization, even if the gonads are intact, was causing a great deal of damage that might have been averted if it had been recognized earlier.

When counselling couples where one partner has a serious disability, either mental or physical, it is sometimes difficult to decide which partner should undergo sterilization. The choice is made easier where there are contraindications to surgery, but in other instances it should, as far as possible, be left to the individuals concerned. They will both need to have an opportunity to explore their situation from every aspect, and to understand what the procedure entails, as well as its irreversibility.

*257/197/1*

The ‘I’m OK, you’re OK’ hands-off approach, in its extremes, can be just as inhumane as rank prejudice. For instance, the practice of burning widows (suttee) is, in my view, rightly condemned and outlawed. There are few practitioners who would try to impose their views directly, but many may imply their prejudices carelessly. Those who have enough self-awareness to avoid doing so may experience a feeling of panic because they are ignorant of a particular patient’s religious customs and rules, and are anxious not to offend. The pressure of time in short consultations heightens the anxiety to establish trust by getting it right first time, rather than feeling your way by trial and error. If, on the other hand, one is very knowledgeable about the customs of ethnic minorities, one will not serve ones patients well if one assumes that all patients in this group adhere strictly to their cultural mores. The best doctors and nurses will try to develop a philosophy that embraces the compromise of individualism in the setting of different traditions and religious dogma. It is more likely these days that a practitioner will be anxious not to offend, and sin by omission, rather than by taking a superior attitude.

*219/197/1*

In all groups except the incest offenders, where the percentages are equal, the patterned offenders have definitely larger percentages of men with homosexual experience, ranging from 50 to 100 per cent. This is in part the result of a carry-over from their more extensive prepubertal homosexual activity.

The greater incidence of homosexual experience among the patterned offenders does not imply a greater quantity (beyond the one time necessary to be counted in incidence) or intensity of experience.

A tabulation of the proportions of men with substantial amounts of homosexual activity shows no consistent differences between the incidental and the patterned offenders. Evidently while the factors having to do with patterned offense behavior have some bearing on whether an offender ever had a homosexual experience, they do not determine whether or not he will go on to more extensive experience.

No significant differences exist in the ages at which the average (median) individuals had their first postpubertal homosexual experience. Neither does the frequency per year differentiate the incidental and patterned offenders in any uniform fashion.

Paralleling the incidence of homosexuality, in five of the six groups the patterned offenders were more neutral or approving in their attitude toward it than the incidental offenders. This is not surprising, since persons who engage in any sort of sexual activity are more apt to approve of it, or be tolerant of it, than those who do not.

*395\161\2*

In examining the degree to which various kinds of sex offenses were committed by offenders of varying marital status it is necessary first to take into consideration the differences in their age levels. Thus, while a high percentage of the peeping offenses (68 per cent) were committed by males who had never been married at the time of their conviction (twenty-three years), this phenomenon is certainly strongly related to their youthfulness. Table 139 presents the marital status of the offender at the time of committing the indicated offense. With the exception of the peepers, the three groups of homosexual offenders had the highest percentages of males who were still single at the time of the offense. The three homosexual-offender groups show no marked differences in their median ages when arrested.

Turning now to the remaining groups of offenses (except for incest), one finds that the percentage committed by men who were still single at time of offense is roughly related to the age-rankings presented earlier: the younger the age at offense the higher the percentage of never-married offenders. It is clear that in the present sample a large number of sex offenses were committed by men who had never been married. This is not unexpected. Many of these are males who had not yet settled down to the typically stabilized sexual patterns for their age and hence were apt to get into trouble. Also, their periods of incarceration often prevented them from getting married.

There is yet another group that lacked the stabilizing factor of marriage at the time of the offense, namely, men who had been previously married but who were currently separated, divorced, or widowed. The proportions of offenses committed by men in this marital status range from 4 to 40 per cent. However, if calculations are based on only the ever married, the proportion of offenses committed by separated, divorced, or widowed men rises from a low of 4 per cent in the incest vs. children offenses to a high of 82 per cent in the homosexual offenses vs. minors.

The incest cases vs. children and minors with fewest offenses by separated, divorced, or widowed men apparently represented offenders with a stable home pattern, although the incest cases vs. adults show that more than a quarter of the offenses occurred after the breakup of the marriage. The marriages of the homosexual offenders were clearly the least durable—in from three fifths to over four fifths of the cases the marriage had been interrupted before the offense. The remaining groups of offenses, comprising the majority, fall between the high-ranking homosexual and low-ranking incest classification.

One other point in connection with marital status is worth examining. It has sometimes been suggested that the temporary absence of a man’s wife from home might serve as a triggering circumstance for the sex offense. We checked the present data on this point, using as a criterion an absence of 24 hours or more, and found it to be a possible contributing factor in a small number of offenses, a total of 50 in all. While the wife’s absence is of minor importance as a possible causative factor from an over-all point of view, if we examine only men whose marriages were intact at the time of the offense, it can play a not inconsiderable role in several types of offense. This can be seen in Figure 25 in which such per cents range up to a high of 23 per cent in the offenses vs. adults.

In summary, for eight of the 14 types of sex offenses, from one fourth to one third of the offenses were committed by males who were married at the time. These eight groups include the heterosexual offenders, heterosexual aggressors, and the peeping and exhibition groups. In contrast to these eight, the three incest-offense groups showed a higher married ratio at the time of the offense, and the homosexual offenses a much lower proportion. All the varieties of offense except incest were preponderantly committed by men who cither were single or whose marriages were not currently intact.

*357\161\2*

The median frequencies, calculated only for those with extramarital coitus, are surprisingly uniform up to age forty-five, lying between 4 a year and 20 a year in every age-period. In the late thirties and early forties this uniformity appears to be a case of the ends of the range remaining unchanged, while large gaps develop between groups. The control and prison groups behave differently from each other: the prison group in early life displayed a high frequency of extramarital coitus of nearly 20 per year, but this frequency dwindled to 5 per year by their early forties. The control-group frequencies held constant at 4 to 5 per year from age twenty-one on to forty-five; this is intermediate to low in the rank-orders. Little can be said regarding trends or clusterings: between ages twenty-one and thirty-five the incest offenders tend to concentrate in the lower portions of the rank-orders.

The median frequencies of extramarital coitus with companions are similar, but the positions of the various groups in the rank-orders change because certain groups were more predisposed than others to have extramarital coitus with prostitutes.

Average frequencies of extramarital coitus with prostitutes were almost always low: 3 to 5 per year. In only three instances were higher frequencies reported (the highest being 10 per year) and these were by numerically very small groups. Indeed, many frequency calculations were not made because there were too few males in the age-period with commercial extramarital experience.

*319\161\2*

Studying the masturbation frequencies of the unmarried who masturbated, one finds that the homosexual offenders rank highest from puberty on. The homosexual offenders vs. adults lead, the homosexual offenders vs. minors are usually second, and the homosexual offenders vs. children fluctuate generally from second to fourth rank.” The control group occupies an intermediate position. The above statements apply to both mean and median frequencies. The lower portions of the rank-orders of frequency are monopolized by the incest offenders and the heterosexual offenders vs. adults and minors.

The position of the homosexual offenders is probably the narcissistic result of their being equipped with the genitalia of the sex they desire as sexual partners. In the case of the homosexual offenders vs. adults a second factor is strongly operative: a larger proportion of them are from the better-educated segment of the population, a segment characterized by great dependence upon masturbation as a sexual outlet.

The fairly high rank of the exhibitionists in adult years may be in part attributed to the fact that their exhibition often involved masturbation. On the other hand, their fourth rank from puberty to fifteen, a period usually prior to the emergence of their exhibitionistic pattern, suggests preoccupation with their genitalia in addition to reflecting their somewhat poor heterosexual adjustment at that age.

The groups with low masturbation frequencies might be explained in the following way. The low ranking of the heterosexual offender vs. adults is the consequence of his frequent sociosexual outlet; however, this explanation does not hold true for the incest offenders vs. children and minors. At present, the only explanation that presents itself is this: all incest offenders have low frequencies of total sexual outlet, and this is reflected in the masturbation frequencies.

The availability of coitus radically reduces the frequency of masturbation among married males. The average (median) husband in the control group masturbated about 10 to 15 times a year well into middle age, where our calculations cease because of sample size. His counterpart in the prison group had frequencies half as great. All the sex offenders except for the homosexuals and exhibitionists had frequencies of masturbation within the general limits set by the prison and control groups. The emphasis upon masturbation which typified the unmarried homosexual offender carried over to some degree into marriage where on an average he masturbated between 15 and 50 times per year, depending upon his age and to which homosexual-offender group he belonged. The married exhibitionist also had high masturbatory frequencies^—about 25 to 50 per year—some of this being, as we have said, in connection with his exhibition.

We asked every man we interviewed what was the maximum number of times that he had masturbated, after puberty, in any consecutive seven-day period. This question was an effort to gain some idea of the physiological capacity for repeated orgasm. By and large, we found that more homosexual offenders had high maximum frequencies than other groups (see Figure 5). The peepers also rate rather high; this in part is due to their frenetic outbursts of peeping plus self-masturbation. The groups which rate lowest in this respect are those characterized by extensive heterosexual activity (the offenders vs. adults being the prime example). The incest groups also rank low, not because of frequent heterosexual activity but because of their low sexual drive and/ or restraint, both being suggested by their low frequencies of total outlet prior to marriage.

*281\161\2*