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.

*245\161\2*

About half the time, men who are infected with NGU do not have any symptoms and would not know they were infected unless they were tested. If symptoms do occur, they include painful urination, a discharge from the penis (which may only be noticed as stains in the underwear), or an itchy or irritated feeling in the penis. Sometimes the discharge may be noticed only after urination. There may also be an alteration in the flow of urine, such as a “spray” or two streams, which occurs because of the inflammation in the urethra. Often these symptoms are very mild. They usually take between one and three weeks after infection to show up, but they may take much longer.

Urethritis can, rarely, progress to infection in the prostate or epididymis, and this may be the first indication that infection is present (see the section on epididymitis and prostatitis). Usually NGU does not cause such symptoms as fever, chills, and nausea. If the urethritis is caused by the herpes virus rather than bacteria, there are sometimes lesions on the genital skin. Although the symptoms of urethritis caused by gonorrhea are usually more severe and occur more quickly after infection than those of NGU, this is not always the case.

Men and women can become infected in the throat with the bacteria that cause NGU. Usually they do not experience any symptoms, although occasionally there can be some mild throat irritation. When a man or woman has an NGU bacterial infection in the anal or rectal area, there are often no symptoms; if they do occur, they may include rectal discharge, bleeding, and pain.

*356\213\8*

First infections generally take longer to heal than recurrences, for both oral and genital herpes. First outbreaks with herpes in the genital area, whether type 1 or type 2, last about ten to fourteen days on average, although they can last for as long as six weeks if not treated. The outbreak may last even longer if a person is taking oral steroids for other medical conditions or is mistakenly applying topical steroids in efforts to treat the sores. It is not uncommon for new lesions to erupt within a few days of each other during first infections. Treatment with oral antiviral medications will shorten both the first episode and recurrent infections (see the section on treatment).

The first symptoms that a person may recognize may actually be a recurrent outbreak from a prior infection; recurrent outbreaks usually last about five to seven days. As noted earlier, some people with herpes are unaware of it when they first become infected and only notice symptoms later, during a recurrence.

The symptoms that are caused by type 1 or type 2 herpes in the oral or genital area are exactly the same. The only difference is that type 2 herpes tends to recur less frequently than type 1 in the oral area, and type 1 tends to recur less frequently than type 2 in the genital area.

The bottom line for most people is that herpes is simply an occasional physical annoyance that can be treated with medication. For many people, herpes doesn’t even cause symptoms. Herpes doesn’t cause cancer (we used to worry about herpes putting women at risk for cervical cancer, but this does not appear to be the case), and in otherwise healthy individuals it doesn’t spread to other areas of the body. It is often the emotional issues that are harder to deal with, as discussed later.

*263\213\8*

The diagnosis of epididymitis is made on examination. A red, swollen, tender testicle on only one side is suggestive of the disorder. An evaluation is usually carried out for urethritis and a bladder infection.

For a urethritis screening test, a man should not have voided for at least four hours prior to the examination. A small swab is inserted a short distance into the urethra, and then material from the swab is examined under the microscope for causative bacteria. (See the section on nongonococcal urethritis for more information about these screening procedures.)

Tests for gonorrhea and chlamydia are usually performed, and a midstream urine sample is obtained for analysis under the microscope and culturing. Both the screen for urethritis and the screen for a UTI are important in helping to sort out the cause of the epididymitis.

Other medical conditions can cause testicular pain and swelling. Torsion of the testicle is a medical emergency that occurs when the spermatic cord and blood vessels that lead to a testicle become twisted and cut off the blood supply to the testicle. This condition can lead to the death of the testicle if not quickly corrected surgically. It usually occurs on only one side, so it can be difficult to distinguish from epididymitis. However, torsion of the testicle usually occurs in young men and has a very sudden onset of symptoms, and there usually is no evidence of urethral infection on examination. Epididymitis typically has a more gradual onset of symptoms, but there are exceptions.

If there is difficulty distinguishing between epididymitis and torsion of the testicle, a study such as a Doppler-ultrasound can be performed to help make the diagnosis. This test measures blood flow to the testicle and, by bouncing sound waves off the internal structures of the scrotum, allows them to be visualized.

Other testicular problems that can be confused with epididymitis are trauma to the testicle (usually a man will know that this has occurred), testicular cancer, and other infections of the testicle such as tuberculosis, which is rare. An experienced health care provider can sort out these possibilities and order appropriate tests to make the diagnosis. For complicated situations, such as failure of the epididymitis to respond to antibiotic treatment, a urologist should be consulted for further evaluation and treatment.

*171\213\8*

What if your partner never wants to discuss sex but still wants to have sex? Possibly he or she has difficulty with open, honest discussion. This may make the relationship difficult in other respects as well. Possibly your partner doesn’t understand the importance of the discussion and is poorly informed about STDs. This may mean that he or she has engaged in risky behavior in the past and may now put you at risk as well. Maybe your partner is afraid to talk about the issue for other reasons. Without talking about it, it’s hard to know. Having sex with someone who won’t discuss sexual health probably doesn’t fit into anyone’s plans for keeping safe. Remember: the decision about whether or not to become intimate with this person is yours. If you decide to not go any further, say no in a clear and unmistakable way to let your partner know where you stand.

Certain partners may try to make you feel embarrassed or awkward for bringing the topic up, or even try to make you feel that you are unusual for raising the issue. Such a person may not be the one for you. Consider the following ten statements from a person who is pressuring someone to have sex without talking about safe sex first, or is pressuring someone to have unprotected sex. Each of the statements is followed by a response that might be helpful, if not in convincing your partner, then at least in helping you keep your priorities straight.

*79\213\8*

Irritable bowel syndrome (IBS). IBS is a very common problem among young women. It may cause pain that is experienced in the pelvis by most women, but the source of the pain is in fact the bowel. IBS causes abdominal and/or pelvic pain, bloating, and constipation or diarrhea. Sometimes the diarrhea and constipation alternate. Usually no structural abnormality is seen on examination of the colon, and no abnormalities are evident with laboratory tests. IBS is a diagnosis of exclusion, meaning that all other possibilities should be ruled out first. Although it is a chronic problem, IBS can be managed with diet, exercise, and medications in most people, and it does not cause more severe problems, such as cancer.

Ovarian cyst. In the normal menstrual cycle, each month one ovary produces an egg to be fertilized. If ovulation (the release of an egg) does not occur, a cyst, called a folhcular cyst, may form. When an egg is released from an ovary, another kind of cyst, called a corpus luteum cyst, may form. These two lands of cysts may grow quite large and may cause pain either on their own or if they rupture. An ultrasound device, which bounces sound waves off internal structures to visualize them, is used to diagnose an ovarian cyst. Most cysts go away on their own, or they can be reduced through hormone suppression with birth control pills or drained through a laparoscopy. Ovarian cysts must be differentiated from ovarian cancer, which usually has a different appearance on ultrasound than a cyst and does not shrink with hormone suppression.

*30\213\8*

Anyone interested in keeping real ageing at bay should do one thing above all others. He should practise the gentle and simple art of artery maintenance. It is now a commonly held belief that you are as young as your arteries. If you keep them clean and efficient, they will service your body well and maintain it in optimum condition.

If you allow them to deteriorate and become clogged, they will compromise the way you live: you may find you rapidly become puffed, you may get angina or you may readily feel tired and become impotent or even forgetful; of course, you may also eventually have a heart attack or a stroke.

It used to be thought that, with age, arteries inevitably became hard and clogged and that once this occurred little could be done to stop the process. Autopsies on road-accident victims and young soldiers showed evidence of ageing in arteries from the age of 18. It was accepted that this process advanced relentlessly.

Now we know differently. Not only is arterial ageing not inevitable but it is preventable. Furthermore, once it has begun, not only can it be stopped but it can also be reversed.

The orthodoxy changed when epidemiologists began comparing arterial health in different populations. They found that in Japan and China atherosclerosis was very uncommon, while in Mediterranean countries it was less common than in Australia or America. If it was an inevitable process, they asked, why were there geographical differences? The answer appeared to lie in lifestyle and diet. This was confirmed when people from those countries with low levels of atherosclerosis settled in America and soon developed signs of arterial disease.

There are five possible steps people can take to maintain their arterial health.

STEP 1

The first step is to modify diet and lifestyle and follow the example of people in those countries with low levels of atherosclerosis by eating a varied diet rich in fruit, vegetables and grains.

It is most likely that it is the total mixture of their diet rather than one component that confers benefits. To start with, cut down on hard animal fats and replace them with unsaturated vegetable fats, fish oil and carbohydrates that occur in fruit and vegetables. In terms of lifestyle, stop smoking and move more. You don’t have to jog or sweat – just walk.

STEP 2

While most premature ageing is self-inflicted, it is never too late to do something about it. There can be as much as a 20-year gap between chronological and arterial age, and the second step in artery maintenance is to lower blood pressure. This is one of the hardest steps to take and requires an ongoing commitment. It’s hard because high blood pressure is silent and doesn’t obviously worry you. But once you have it you’re in a vicious cycle. High blood pressure contributes to hardening of the arteries, which in turn leads to higher pressure.

There are several things you can do to break the cycle, bring the pressure down and give your arteries a chance to recuperate. You can change your diet, move more, lose weight, stop smoking, reduce salt, increase potassium, calcium and magnesium and try to relax.

If these measures are not enough to bring about a result, they can be combined with a medication plan. Reducing high blood pressure is vital for arterial health.

STEP 3

The third step is controversial: it is the use of aspirin to clear the arteries. Some experts advocate an aspirin a day. ‘Feeling old? Take an aspirin,’ is their answer.

Not only is aspirin a blood-thinner that helps to keep arteries free of clots, but it is also thought to help the body build auxiliary blood vessels around clots or blockages. In addition, it is believed to decrease inflammation in the walls of the vessels and thus promote a smoother flow. Aspirin is also known to reduce the incidence of strokes – especially the practically undetectable mini-strokes that are often associated with memory loss. But while aspirin can confer substantial benefits, it can also cause substantial harm and must never be taken without medical approval.

STEP 4

The fourth step is to take anti-oxidants in moderation to open up arteries. If you slice open an apple and leave it exposed, its surface will oxidise and go brown. Had you squeezed lemon juice over the surface first, it would have remained white. The juice contains vitamin C, an anti-oxidant that would have kept the apple from rusting. In the body, anti-oxidants like vitamins C and E do the same thing. Oxidation generally ages arteries. As you get older your arteries become more clogged with fat deposits. These clogs contain high levels of oxidised lipids.

Taken together, vitamins C and E may help to keep your cardiovascular system healthy by reducing the amount of harmful build-up on the walls of the arteries.

While the anti-oxidant theory is convincing, it is yet to be proved conclusively. While it is accepted that people with a high build-up of oxidised fats have higher rates of heart disease, it has recently been hinted that vitamin C may actually accelerate coronary artery disease.

STEP 5

The fifth step in arterial maintenance involves countering homocysteine, an amino acid that in high concentrations in the blood disturbs the inner lining of the arteries and significantly increases the risk of heart attacks. Homocysteine levels are known to build up when a person’s intake of folate and vitamin B6 is low.

Increasing folate and B6 has been shown to reduce homocysteine. But until there is scientific evidence that taking supplements of these vitamins will also reduce heart attacks, doctors prefer people to get folate and B6 from natural sources. B6 is found in meat, poultry, fish, bananas, yeast, bran and nuts. Folate is found in liver, dark-green leafy vegetables, dry beans, peanuts, wheat germ, whole grains and yeast.

*119\105\2*

Sleep disorders

Prolonged sleep deprivation also takes its toll on brain function. Sleep apnoea (see ‘Not Tonight Darling, I’m Snoring’ on p. 30) and disorders such as periodic leg movement and insomnia may cause such deprivation.

As they age, many men experience a disintegration in their diurnal rhythms. Their internal clock becomes less efficient and they spend half the night awake and half the day asleep. With this, their ability to concentrate deteriorates.

Early-onset dementia

Alzheimer’s and other dementias can start in the 40s and remain undiagnosed for long periods. They become evident when the man’s behaviour changes. Some men become socially inept and disinhibited. A disinhibited man will make poor decisions, will be impulsive and will not take all factors into account. Other men become withdrawn. They stop interacting and seem emotionally flat. They lose their drive and are not sufficiently organised to get to make a decision.

*93\105\2*

Some people call them joy pills. To others, they are nature’s Prozac. In Australia, they’re on the shelf in bottles labelled St John’s wort.

St John’s wort (wort means plant) has been used as a medicine for thousands of years and is now gaining popularity as an antidepressant. In Germany, which is known as the world’s herbal heartland, it is reported that more than 60 million doses of this herbal extract are prescribed every year for conditions such as moderate depression, fear and nervous disturbances.

Now the esteemed British Medical Journal has published a German study showing that St John’s wort (hypericum) is effective enough to be considered as a first-line treatment for mild to moderate depression.

The study showed that in moderately depressed people not only was this herbal extract as effective as mainstream tricyclic antidepressant medication, but it also had advantages in the way it could be tolerated by patients, and in their willingness to con-tinue taking it.

While this study found hypericum to be safe and to improve quality of life, the trial was limited to 8 weeks. The questions that now arise are whether the extract is effective and safe in the long term and appropriate for more severe forms of depression.

From an Australian point of view, it would have been more useful if these researchers had compared the extract with the modern antidepressants known as selective serotonin re-uptake inhibitors, or SSRIs. They did the comparison with the popular tricyclic, imipramine, because it is the most frequently prescribed antidepressant in primary care in Germany.

Commenting on the study, an editorial in the journal confirmed the research had provided further evidence for the effectiveness of St John’s wort, but said its place in antidepressant treatment was not yet fully established.

Such British caution contrasts strongly with the enthusiasm for the extract found on the Internet. One site, which offers joy pills for sale, claims that St John’s wort is a clinically proven all-natural mood elevator and stabiliser and is for anyone who wants to ‘decrease anxiety, gain greater mental clarity, get a good night’s sleep, enhance self-esteem, feel good (but not high), reduce guilt… create a level emotional playing field – on which to build a good life.’

But these pills shouldn’t be bought over the Internet because not all providers are entirely reliable and the consistency of preparations varies.

When the LA Times newspaper did a spot check of retail St John’s wort supplements available in Los Angeles, its independent laboratory tests found a marked range in the potency of different brands. Furthermore, of the 10 brands sampled, none of the laboratory results matched the claims made on the label about potency.

In Australia, this is less of a problem. All herbal preparations sold over the counter have to comply with basic standards set by the Therapeutic Goods Administration. Their producers have to have Good Manufacturing Practice licences, and any therapeutic claims have to be verified and approved.

Herbal preparations that have been listed in the Australian Register of Therapeutic Goods all carry an ‘AUST L’ number on their labels. Preparations with an ‘AUST L’ number are inherently low risk in nature. If this number is missing, the preparation has bypassed the authorities, and there is a fair chance it was personally imported or bought off the Internet.

Hypericum is available as an oil, tea, tincture, tablet, pill or capsule. The dose used in the German journal study was very large, at 350 mg of hypericum three times daily, in capsule form.

What is needed now is not another clinical study on raw extracts of hypericum but work that will isolate and characterise the active substances (or substance) and determine their likely pharmacological site and mechanism of action and their metabolic fate.

This had been done with numerous other useful medicines of plant derivation, from opiates to salicylates, and was the way of achieving better therapeutic agents.

In the past few years, there has been growing interest in St John’s wort. Two books about its effects on depression have recently been published. One suggests this herb could change the way depression is treated in America. The other is a how-to book about using it as an antidepressant.

Not everyone can take St John’s wort. There have been warnings against its use by children, in pregnancy, by breastfeeding mothers, by people with high blood pressure and by those taking other medication such as antidepressants, oral contraceptives and anticonvulsants. Its side effects include stomach upsets and, in rare cases, sensitivity to light.

Some of the more extravagant claims made in the name of hypericum include assertions that it has antiviral, anticarcino-genic, anti-inflammatory and antibacterial properties. Like many herbs named after saints, it is said to have spiritual effects.

If any of this is remotely true, St John’s wort may become the wonder drug of the new century. Move over aspirin!

*70\105\2*

In the life cycle of a melanoma there is a dreaded moment that no doctor can predict. It is the moment when the first malignant cell detaches itself from the melanoma and quietly slips into the bloodstream.

Once in the blood, it can travel to distant parts of the body. Other cells follow, and their combined potential for destruction is considerable.

If a melanoma is detected and removed before this crucial moment occurs, a man’s chance of survival is 100 per cent. This is why early detection is crucial.

In Australia, men fare far worse in a battle with melanoma than women. Although the incidence is almost equal – 3695 men and 3081 women were diagnosed with melanomas in 1994 -there is a vast difference in the death rate. In that year, 609 men died, compared to 288 women. If all factors are matched and a man and woman of the same age have identical melanomas in the same place, the woman’s chance of survival is far greater than the man’s. Men also have double the chance of developing a second primary melanoma.

For these reasons men should be highly vigilant about their skin. Unfortunately, in reality they pay less attention to it than women do. In fact, it is often women who first discover men’s melanomas.

Boston University’s School of Medicine conducted a survey to determine who ‘discovers’ melanomas and found that women are more likely than men to identify not only their own (66 per cent versus 42 per cent) but also their spouses’ (23 per cent versus 2 per cent).

Men tend to get melanomas on their back, head or neck. Women often get them on their legs, which might partly explain why they detect them sooner.

On rare occasions melanomas grow in unexpected places such as under nails and inside the mouth or rectum.

Even if their melanoma is in an obvious and visible position, men often fail to notice it because they expect that if they get a melanoma it will arise from a pre-existing mole and will be raised and ugly.

But 70 per cent of melanomas arise on normal skin and in the early stages are flat and look no different from a freckle. They do not itch, bleed or do anything to attract attention.

The depth of a melanoma usually determines a man’s likelihood of survival. If it is thinner than a credit card (less than 0.75 mm) his chance of survival is 100 per cent. If it is thicker than a 50 cent coin (3 mm) his chance drops to about 59 per cent. If it grows just a little more, to a thickness beyond 4 mm, his chance is less than 30 per cent and death occurs quickly, usually within 3 years.

Although Australia has the highest rate of malignant melanoma in the world, its survival rates are generally higher than those of other countries because of the high proportions of thin lesions.

About 15 years ago the incidence of melanoma was a touch higher among women but now it’s higher among men. After the age of 45, the incidence among women flattens out, but among men it continues to rise. This is probably due to their different habits of sun exposure. As women enter childbearing years they reduce sun exposure and protect themselves more. Men continue with their outdoor recreational activities. Intermittent exposure, such as on weekends and summer holidays, is more risky than continuous exposure. Men who work outdoors develop a tan and thickened skin, which gives them some protection against the sun.

The steady rise in melanoma deaths that was witnessed in Australia last century has been reversed. Figures show the number of Australians dying from melanoma peaked more than a decade ago. But while there is a distinct drop in the death rate among women, there is only a flattening in the death rate among men. The drop is attributed to greater awareness and increased early detection. It is anticipated that the death rate among men will drop in the next decade.

In the meantime, however, continue to examine yourself for odd spots (usually between 5 and 10 mm in diameter – the size of a shirt button) and don’t forget to check out-of-the-way places like the soles of your feet and between your toes.

*46\105\2*