General practitioners are familiar with the idea that illnesses are seldom due to purely physical or purely emotional causes. The input of each side has to be weighed at every consultation. Seminar training can foster the skill of keeping an open mind, and promote the study of the interaction between the body and the mind, which is especially important in the sexual area of the patient’s life.

Doctors learn to look for and think about direct clinical evidence in the ‘here and now’ of the consultation. Such evidence can provide powerful hints about the patient’s predicament. If and when the patient chooses to talk about past relationships and memories, these will have been remembered because they have special meaning for the patient in the present. They are then far more relevant to the current problem than answers provided in reply to questions about the past history.

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Establishing rapport is to do with making the patient feel at ease. Ascertaining the name the patient likes to be called is useful; it may well be different from the names given at registration. ‘Matching’ is a technique which may be needed early on to get in touch with the patient; for example, adopting the patient’s tone of voice or posture can be a powerful signal that one is adjusting to their wavelength. A patient’s diffidence is reduced by these means and worries are thus less likely to be held back.

Does it matter what sort of clothes the doctor wears? Instinctively, one would say that ordinary dress would be more welcoming than white coats. The fact is that GPs tend to wear ordinary clothes in their surgeries and clinic and hospital doctors white coats, and the public are used to this. In one study about clothes in family planning consultations (Stewart and Woodhouse, 1987), the majority of patients in a community clinic setting thought that the doctors should wear white coats. This view extended throughout all age groups, although the majority was not quite so large among the under-20s.

Once rapport has been established, the consultation can proceed more effectively because the doctor/patient relationship is in harmony (Freeling and Harris, 1984). When doctor and patient get to know and trust each other, the first phase of the consultation may become redundant. However, as with all relationships, rapport may have its ups and downs and work may be needed to rebuild rapport from time to time.

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Miss P. attended a clinic asking for non-allergenic condoms. The nurse enquired why and was told that the patient was allergic to ordinary sheaths. Undetered by the patient’s defensive manner, the nurse enquired further and was told that the patient was sore after intercourse. She explained that this might be due to many causes other than allergy and put the patient through to see the doctor. Initially the patient appeared quite angry: ‘What was this all about? All I want was the condoms.’ The doctor resisted the impulse to give a lecture on the causes of soreness, merely saying that allergy to condoms was really rather rare, and could Miss P. tell her some more about what was wrong? Miss P. then told or how she had started to be sore after intercourse using condoms with her partner about two years previously. She knew it was the condoms because it was all right without, but they usually used condoms because he did not want her to get pregnant. She hastened to explain in some detail that he already had two children by his wife from whom he was separated. The doctor wondered silently why this decision not to get pregnant needed such anxious defence and asked, ‘Had you thought about changing to a different method of contraception?’ There was a long confused explanation – all about Pills upsetting her and him wanting to look after her and make sure she would not get pregnant – and the doctor did not clearly understand what Miss P. meant. She said, ‘It seems to me that you are saying that he needs to be sure that you are not going to get pregnant?’ There was a long silence. The doctor looked at Miss P.’s bowed head and eventually reached out and touched her hand saying, ‘You have some strong feelings about this?’ Miss P. looked away and said in a muffled voice, ‘I’m 28 now. I want to get married and leave home and have a family of my own, but he won’t get a divorce in case he can’t see his children again.’ There was another long silence.

‘What happened two years ago?‘ the doctor asked, remembering the length of the history. ‘He went back to his wife then but couldn’t stand it and left again.’ Miss P. compressed her lips and then burst out, ‘It isn’t fair, I know he would be happy with me but he won’t risk getting married again. If only we had a baby, I know it would be all right. He would love a baby, he loves children, he can’t bear to be away from his children. If I had his baby it would be all right, he would marry me then,’ and she wept, hot, angry, body-jerking tears. When she had sobbed herself to a standstill, work could continue on the real reason for her ‘soreness’ when condoms were used.

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A sad woman in her mid-30s was referred to hospital asking for her sterilization to be reversed. She came with her husband. They were living a completely independent life in their own home. The woman had attended a school for children with learning difficulties. She was an only child and her mother had been deeply distressed when she became pregnant at the age of 18. At her mother’s insistence the baby was placed for adoption, and to prevent any further illegitimate pregnancies a sterilization was undertaken. The woman had been acquiescent over her situtation until she had married, and then both she and her husband wanted a child. She had felt no anger at the time of the sterilization, clearly being completely unaware of the likely consequences.

This situation is unlikely to occur today, but the consequences of past eugenic policies can still be seen. Today it is recognized that the children of handicapped parents tend to revert towards the average intelligence of the population. This new knowledge has helped to change the attitude towards childbearing by women with a mental handicap.

In 1987 arguments were heard in British legal courts concerning the possibility of authorizing the sterilization for a severely mentally handicapped girl aged 17. The case was heard in the lower courts and eventually reached the House of Lords. The arguments on both sides were complex, but the underlying principle agreed by both sides was that if the operation took place it would be for the ultimate benefit and protection of the girl rather than the community (Lee and Morgan, 1989).

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Doctors, nurses or other health care workers who are new to an area that includes significant numbers of patients from a different cultural group may find themselves faced with a barrage of folk-lore from older hands. This is not always dispassionately given; those that have been in the field a long time may have become discouraged and unreliable witnesses, passing on hearsay rather than first-hand experience. Generalizations tend to fuel anxieties rather than enlarge one’s views, and most health care professionals have to learn on the job. This may involve re-learning and adjusting preconceived ideas.

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The gradual shift over the past century from the concept of punishment to that of rehabilitation has resulted in the development of innovations such as probation, parole, indeterminate sentence, juvenile courts, clinicians working in prisons, and sexual psychopathy laws. Some of these and other recent developments stem largely from the concept of the lawbreaker as mentally ill or at least as having emotional problems, and in either case having a diminished responsibility for his behavior.

The purpose of the sexual psychopath laws is to diagnose persons with dangerous sexual propensities, to remove them from society, and to treat them so that they become no longer dangerous. The first sexual psychopath law was passed in Michigan in 1935, but was subsequently declared unconstitutional; consequently Illinois has the distinction of being the first state whose sexual psychopath law (adopted in 1938) has survived a higher court test. Since then sexual psychopath laws have been enacted by 28 states, ranging from the Eastern seaboard to Hawaii.

The legal concept of sexual psychopathy is based on two assumptions about which considerable doubts have been expressed. The first assumption is that there is a clinical entity or syndrome of psychopathy or of a psychopathic personality. The concept originated with an English psychiatrist, J. C. Prichard.1 He described patients who were “morally insane” because, although their intellect was unimpaired, they were “incapable of conducting themselves with decency and propriety in the business of life.” Later in the nineteenth century the hypothesis was advanced that these persons had some hereditary weakness of the nervous system, and the label “constitutional psychopathic inferior” was attached to them. Still later, when the vogue of explaining the foibles of the human personality on constitutional or hereditary grounds had passed, the concept of psychopathic personality remained to plague the psychiatric nosology and theoreticians.

Hakeem points out that psychiatrists have conflicting opinions. It appears that workers in this area have quite different ideas about whether there is such an entity as the psychopathic personality, and, if so, what constitutes it. There is also a disagreement as to whether psychopaths are more criminal than others and, if they are, whether their criminality is of a serious or minor nature. Despite the protestations of Cleck-ley and others, it seems as certain now as it did when the term originated that this is a wastebasket classification which is used for persons whose actions are disapproved of or not understood by clinicians and the lay public. Still later the term “sociopath” or “sociopathic personality” was originated and is in use today. It implies that the difficulty lies in an individual’s interaction with and adjustment to society rather than within his own personality. Although much can be said for changing the emphasis to this newer concept, it seems that essentially the same sorts of people with the same sorts of maladjustments are being described.

Even if one were to grant the existence of such a syndrome as psychopathy, a second assumption that there is a special brand called “sexual psychopathy” is seriously open to question. Cleckley (who has written more on the psychopath than anyone else and who must be regarded as the leading exponent of the psychopath as a clinical reality) lists 16 different criteria which compose this syndrome.4 In only one of these does he mention sex, and then it is only to point out that the psychopath’s sex life is impersonal, trivial, and poorly integrated. Definitions by various clinicians attribute to the psychopath habitual and purposeless lying, purposeless stealing, and inability to feel close, emotional attachments to others, and mention little or nothing about his sexual behavior.

Because the term “sexual psychopath” is a legal, rather than a medical, term, it has been defined differently from legislature to legislature throughout the country, and interpreted differently from court to court. This is in contradistinction to laws dealing with a medical entity, such as laws requiring persons with a venereal disease to take medical treatment. A smear or a blood test can determine whether a person has a venereal disease, without a legal definition of venereal disease being necessary. The sexual psychopath laws are in this respect some what analogous to the legal definition of insanity in criminal proceedings, where the M’Naghten rule criterion of criminal responsibility in insanity is considerably different from the medical definition of insanity.

In determining whether or not a person is a sexual psychopath the examining clinicians must perforce define sexual psychopathy regardless of their own opinions as to whether such an entity exists outside the law books. The important criteria appear to be the compulsiveness, repetitiveness, and/or bizarreness of the sexual behavior. While the law frequently insists that the person must be dangerous or, as in California law, “a menace to the health or safety of others,” this proviso is often loosely interpreted. Consequently, a man who repeatedly exposes his genitalia publicly stands a better chance of being adjudged a sexual psychopath than a man convicted once, or even twice, of the rape of an adult woman. The exhibitionist is regarded as mentally ill, whereas the rapist seems to be regarded as a person with normal impulses, but poor control.

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The problem of premeditation poses many difficulties, not the least of which is its intimate relationship with the concept of responsibility in criminal behavior. In order to cast the widest net, the courts and the law have generally sidestepped questions of premeditation by invoking rules which imply that all intentional acts are premeditated with the exception of those performed by a legally insane person. That is to say, if the person knew in some sense the difference between right and wrong, the act was premeditated, excepting, of course, crimes resulting from accident or negligence. Some of the general difficulties of this view as it applies to criminal responsibility have been outlined previously in Chapter 32 on criminality. In many cases courts will reduce charges to take account of the very obvious lack of planning which preceded the criminal act, but this reduction in charge or penalty is equally often due to other mitigating circumstances.

What is usually meant by premeditation is that the offender planned his act and meditated on it before the commission of the crime. The heinous character of this process seems to derive chiefly from the offender’s rejection of this opportunity to change his course of action, but also in part from the supposed satisfaction he takes in contemplating his future criminal behavior.

For the purposes of the present analysis all offenses have been classified either as premeditated, intermediate, or opportunistic. There are, however, 66 cases in which the offender claimed he was unable to recall or report on the circumstances surrounding the offense. Explanations for this total or partial amnesia were often vague, but typically included drunkenness, fright, or a confused emotional state. These cases are in addition to 316 in which there are gaps in the data on this point for other reasons, such as denial of the offense, failure of the interviewer to ask the appropriate questions, or incomplete official records. The remaining four fifths of the total sample serve as a base for the present analysis.

Premeditation is clearly a phenomenon that constitutes a continuum. On the one hand there are those offenses in which the time, place, object, and even technique are admitted by the offender to have been fixed in his mind well before the act was committed. Cases of real planning would be illustrated by preliminary telephone calls, signing into a hotel or motel room with a female or male sexual partner, setting the stage for sexual activity by parking in a secluded or deserted spot, supplying an underage girl with whiskey or wine, and similar clearly oriented non-spur-of-the-moment behavior. While it is likely true that the offender did not have a precise plan of his exact step-by-step progress, his sexual intentions may be considered definite, though the particular behavior and timing with which he carried them out were controlled by the turn of events. Thus the action of young men in going out to a bar often has no specifically premeditated sexual aim, but during the evening opportunities for sexual behavior may be recognized and followed up. Premeditation in this second sense includes not only acts that were thought about and planned before the event, but also acts that it was intended would evolve out of the: individual’s regular activity. A third sort of offense also included as premeditated was that in which the illegal sexual contact or behavior (such as obscene-note writing) had been repeated over a period of weeks or months, or sometimes years, as was the fact in many incest cases. While the question of the compulsive aspect of such repetitive behavior might be raised, these offenses appear to be properly classified as premeditated rather than opportunistic.

At the other extreme are the cases of truly opportunistic offense behavior. Here fall the apparently impulsive acts in which the subject takes advantage of an opportunity that he had little or no part in planning or creating. This behavior is sometimes explosive in nature, and the result of the unexpected breakdown of the offender’s controls. Some exhibition cases fall in this category: the male had no previous thought of exposing himself, and finds himself doing it almost as in a dream, without conscious volition. Some opportunistic offenses may be a logical outgrowth of prior sexual activity, as when petting suddenly turns into rape. Such opportunistic offenses might be said to grow out of fertile ground, but since sexual impulses are a common denominator of mankind, distinctions in the degree of conscious foreplanning are a device for sorting which, though a weak tool, provide an aid in describing the mechanisms of such behavior.

Finally, cases which did not fall into either of the above two classes of premeditated or opportunistic, but seemed a mixture of both, were tabulated as intermediate. Premeditation at a less than fully conscious level, predilection for a certain type of illegal act, and other similar mixed types would fall here.

There can be little doubt of the predominance of the premeditated offense. It ranges from 70 per cent among the force offenses against adult females to 94 per cent among the homosexual offenses against adults. In fact, in ten out of the 14 offense groups over four fifths of the offenses were premeditated. Few of the offense types show higher than 10 per cent opportunistic behavior, and the majority cluster between 3 and 7 per cent. The mixed or intermediate degree of premeditation ranged from 0 to 21 per cent in the 14 subgroups.

There are, however, some clear differences in the degree to which premeditation is evident. In force offenses, although roughly three fourths were considered definitely premeditated, there was relatively less premeditation and correspondingly more opportunism than in other types of offenses, although the differences were not large. All the incest groups were extremely low in clear-cut opportunistic behavior (actually only four cases were so classed), as might be anticipated from the conventional home setting of their offense, as well as from its characteristic repetitive quality. In contrast, 14 per cent of a pedophilic group, heterosexual offenses vs. children, were classed as opportunistic. In summary, it can be said that while premeditated behavior strongly predominates, opportunistic behavior, when it does appear, seems more likely to occur in the offenses, such as force and pedophilia, that are further from the social norms.

*360\161\2*

The overwhelming majority of males whose marriages terminate continue heterosexual coitus afterwards. In terms of age-specific incidence of total postmarital coitus, the figures vary from 54 to 100 per cent. By and large, 90 per cent or more of most groups had postmarital coitus in any age-period up to forty-five. Thereafter sample size precludes exact statements, but it is evident that increasing age reduces the incidence. Prior to this aging effect the groups with the lower incidences (85 per cent or less) are the homosexual offenders and, in two age-periods, the heterosexual offenders vs. minors.

The age-specific incidence of postmarital coitus with companions is very similar, basically, to the incidence of total postmarital coitus, though the varying emphasis on prostitution causes some shifts in rank-order, especially in the case of the exhibitionists. Aside from the homosexual offenders, one may generalize that at least seven out of every ten separated, divorced, or widowed men had postmarital coitus in every five-year age-period up to age fifty. At younger ages the incidence percentages, again excepting the homosexual offenders, are commonly 90 to 100, but in the late thirties and thereafter figures in the 70s and 80s predominate.

The aggressors and offenders vs. adults and the prison group generally occupy the upper portion of the rank-orders, while the homosexual offenders monopolize the lower with between half to three quarters of them having had coitus in the various age-periods. The figure for the three high-ranking groups just mentioned is over 90 per cent in the age-periods up to age thirty and over 80 per cent thereafter. It would seem that most of the groups with high age-specific incidences of premarital coitus likewise have high proportions engaged in postmarital coitus, and that those with low premarital incidences again present low figures after marriage has terminated.

The age-specific incidence of postmarital coitus with prostitutes varies from 21 to 90 per cent, with most groups falling in the 40-60 per cent range (see Table 80). It is interesting that the groups inclined to have commercial sexual relationships prior to marriage do not necessarily display this predilection after the end of marriage. However, the exhibitionists, who were inclined toward coitus with prostitutes not only before marriage but also during marriage, continued this tendency after their marriages ended; they rank first in incidence of postmarital coitus with prostitutes from ages thirty-one to forty-five.

One of the interesting aspects of these incidence data is that the homosexual offenders vs. adults—our most homosexually oriented group—surpass a number of other groups in the number of men paying for postmarital coitus. One possible answer would be that the ever-married homosexual offenders are not only sufficiently heterosexual to seek females (note they rank second in number of extramarital partners), but are sufficiently accustomed to the promiscuity and prostitution frequently encountered in the homosexual milieu to be slightly more inclined toward female prostitutes than the other homosexual groups (whose members are more interested in children and minors and who, in consequence, have less contact with homosexual prostitution) and some of the more inhibited nonhomosexual groups. Another possible answer would be that the ever-married homosexual offenders vs. adults are insecure about their heterosexual status and, therefore, tend to rely on prostitutes whose opinions are of no concern. Note that in their proportion of total outlet derived from extramarital coitus these offenders found more in prostitution than did a number of other groups, including the other homosexual offenders.

There is no over-all tendency for the age-specific incidence of postmarital coitus with prostitutes to increase or decrease with age up to fifty. Instead, the comparative groups manifest great diversity. Among the offenders vs. adults, the prison group, and especially the exhibitionists, there is an increase in incidence as the individuals grow older. Among another three groups (the offenders vs. minors and the homosexual offenders vs. children and minors) there is a decrease. Other groups remain rather uniformly high in their percentages (as the offenders vs. children) or low (homosexual offenders vs. adults). Lastly, the control group shows neither uniformity nor trend in its fluctuating percentages.

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While in recent decades there have been more and more statements that masturbation is physically harmless and the morality-through-fear school of thought has diminished, there are still many males who worry or have worried over the harm their masturbation may do. Since such anxiety is ordinarily concomitant with the masturbation (generally ceasing when masturbation ceases), we have calculated for each group the total number of man-years during which masturbation occurred and the percentage of those years during which there was anxiety concerning possible ill effects of such masturbation. In this calculation we have not differentiated between mild anxiety, such as might arise from the idea that masturbation would weaken one, and extreme anxiety, such as might stem from a belief that masturbation causes insanity.30

The groups that worried most were the incest offenders vs. adults and the peepers; the exhibitionists rank second, and the aggressors vs. children and aggressors vs. minors tie for third place. At the other end of the scale, those with least anxiety include the incest offenders vs. minors, the heterosexual offenders vs. adults, and the prison group and homosexual offenders vs. adults.

It is clear that general type of offense does not correlate with amount of masturbatory anxiety: note that the first and last ranks are occupied by incest offenders. Age is also no uniform factor; sharing first rank are our oldest group and one of the youngest. While this last does not disprove our impressions that more intense anxiety is commoner among younger males, it does show that some measure of worry persists in the young who theoretically should be more informed about the harmlessness of masturbation. More surprising is the fact that there is no clear relationship between frequency of masturbation and anxiety. One might logically have assumed that high frequency would generate fear about the consequences or, conversely, that high frequency indicates lack of anxiety. In any case, these and similar ideas based upon frequency alone prove useless. Lastly, there is no clear relationship between anxiety and the proportion of total sexual outlet derived from masturbation. About all that can be said is that a small proportion of total outlet seems associated with a small amount of anxiety.

However, if proportion of total outlet and frequency are considered

together, a meaningful correlation with anxiety becomes evident. This calculation is muddied by the fact that our frequency figures are expressed in terms of five-year age-periods, whereas our anxiety figures are simply total computations. It would have been better to have had age-specific incidence figures for anxiety, but this was not discovered until very late in the analyses, and the increased precision was not felt to be worth the large task of going back to the raw data and punching new cards. Nevertheless, certain generalizations may be legitimately made from the available data, and these are more clearly substantiated by the figures relating to early postpubescent life. The incest offenders vs. minors constitute an inexplicable exception to the generalizations. We can suggest that:

A relatively small proportion of total outlet (under 60 per cent) derived from masturbation, coupled with a masturbatory frequency of once a week or less, is accompanied by a small amount of worry.

For groups whose members derive two thirds to three quarters of their outlet from masturbation, the amount of worry appears surprisingly constant (and moderate) despite variation in the frequency of masturbation.

Groups whose members derive three quarters or more of their outlet from masturbation and whose masturbatory frequencies are less than 1.5 per week are the most prone to worry. One may not assume that the high proportion of total outlet indicates difficulty in sociosexual development since the aggressors vs. children and minors were heterosexually quite active even in this puberty-15 age-period.

The moderate to small amount of worry experienced by the homosexual offenders is associated with the highest masturbation frequencies (total median frequency of 1.5 per week or more), which suggests that habituation dulls the edge of anxiety.

In any case it is quite clear that worry over masturbation is a complex phenomenon. Its duration and intensity undoubtedly depend not only upon what one has heard concerning the consequences, but also upon whether or not one regards masturbation as a proof of heterosexual ineptitude and/or a sin. The inability of young males to stop masturbating or even seriously to reduce the frequency for any long period of time may in itself be a source of considerable anxiety—the feeling of being in the grip of some habit beyond one’s control is disquieting to most people, and especially to males in our culture who are supposed to assiduously cultivate “will power.”

It is both curious and unfortunate how worry concerning masturbation persists in our society. One can, of course, point out that some of the worry represents a survival of past belief, and that the recent statements denying its harmful effects are often so qualified (e.g., “harmless unless excessive”) as to defeat themselves. Nevertheless, a substantial proportion of the males we interviewed had worried despite their knowledge that masturbation is well-nigh universal and despite the fact that not one of them reported being physically harmed by it. It is amazing how few persons asked themselves why a loss of semen in masturbation should be harmful while a loss of semen in coitus should have no ill-effect; no one grasped the concept that if masturbation were harmful, marriage would by the same token be suicidal.

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Incest with sisters seems a phenomenon of early life: five of our eight cases were aged seventeen to nineteen at the time, and an additional two were twenty-two. This youthfulness is logical—incest is unlikely among older individuals who have left the parental home and who have developed the ability to obtain sexual partners. None of the males were married at the time of the offense and only one of the eight appears to have had a high coital frequency at that time. As to their heterosexual lives in general, not much can be said, but they tended to have few female friends during their late teens. It is, however, significant that the sisters were without exception younger than the males, and half were younger by five or more years. One sister was a child, two were adult (eighteen), and five were between twelve and fourteen inclusive. There is the suggestion of exploitation in this age discrepancy, and in the case of the child-sister force was employed. In at least half of the cases the incest was a well-established activity, in two cases it was brief, and in another two the duration is unknown. Additional evidence that this incest is scarcely an impetuous spur-of- the-moment act lies in the fact that none of the males were intoxicated at the time—the usual “I was drunk” excuse is conspicuously absent. There were no alcoholics in the group, and only two heavy to moderately heavy drinkers.

While half had had some homosexual experience, there were no well-developed cases of homosexuality.

The incest offenders vs. sisters do not appear to be given to other sex offenses or to any crime. Five had no other sex offense, two had been convicted of exhibition, and one was an aggressor vs. children. Their nonsexual offenses seem, aside from one forgery conviction, trival: drunk and disturbing the peace, assault and battery, disorderly conduct, etc.—of these there were four instances. The picture is not one of professional criminality nor of aggression.

Five of the eight had a definite mental handicap. Three were feebleminded and two were referred to as “borderline.” One other was labeled “dull” by the interviewer, another was classed “low average,” and only one was of average mentality. Along with their mental defectiveness, half of them had a low sexual responsiveness to visual stimuli. Mental deficiency, often including that of the sister, plus a Tobacco Road family milieu seem to be the essential factors in these cases.

In summary, one is left with the impression of a group of individuals who are neither antisocial nor drunk nor badly maladjusted—they are simply well-intentioned but stupid. Consequently they blunder into conflict with society in the sexual as well as other aspects of their lives.

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