Mens Health Blog. Medical Blog

The most important skill that doctors learn in seminars is to tolerate not knowing. Neither the patient nor the docor has the truth, which has been described as ‘a reality that exists in between; in between two people seeking it; in between psychoanalysis, sociology, psychology, economics and religion . . . truth can be seen or glimpsed, not possessed’ (Symington, 1986). Psychosexual doctors learn to stay in ignorance with their patients, searching for a glimpse of the truth, for as T.S. Elliott (1954) says in his poem East Coker

In order to arrive at what you know

You must go by a way which is a way of ignorance.

In order to possess what you do not possess

You must go by the way of dispossession.

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It is important that the patient’s agenda always comes before the doctor’s agenda. The patient’s agenda may be overt or covert (the hidden agenda). The agenda may include that of the partner, whether present or absent at the particular consultation. Family planners encourage patients to bring their partners with them to a consultation. Seeing a couple together may be beneficial so that the method chosen can be one that suits both partners.

Neighbour calls the line which the patient has been rehearsing in the waiting room the ‘opening gambit’ (1987). The patient may well have more than one of these at the ready. Perhaps a ‘respectable’ line such as, ‘The Pill is giving me these awful headaches, doctor’, and a line about her fundamental problem such as, ‘My husband is unemployed and has lost all interest in sex’, which could be used if the time is felt to be ripe. The respectable line is far more likely to be used with its lower risk, if the doctor does not make good eye contact initially or if he pre-empts the patient’s offering by asking a question.

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Miss P. had correctly observed the connection between the use of condoms and her soreness; if it had not been for the defensiveness about her explanation of her partner’s need for her to avoid pregnancy it might have been accepted at face value and not explored further. How very important it is to pay attention, not just to what is said, but the manner in which it is said.

Patients may present many physical complaints. One attended for a repeat of her contraceptive pill following a termination of pregnancy. She complained of an offensive discharge present since the termination and wondered if she had an infection. Examination revealed a very normal looking vagina and the swabs were all negative. The doctor was then able to discuss with the patient what the termination had meant to her and explore her disgust with herself for what had happened. Another, respectable and dowdy patient, married to a boring, pompous older man, asked to be fitted with a diaphragm and then returned repeatedly asking for an examination and swabs to be taken. The doctor was irritated by the apparendy meek approach from the patient and was reluctant to repeat the examination. The patient always managed to manoeuvre the doctor into taking more swabs. When the meaning of this (looking for ‘badness’) was explored, the patient eventually revealed that she had been a wild teenager and had fantasies that her vagina was the place from which this bad and dangerous person might erupt again. Coming to terms with herself, she was able to recognize that she was deeply unhappy in her relationship with this man whom she had married hoping that he could control the dangerous side of her nature.

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It is clear from all the literature on sterilization that there is a general consensus that counselling before the operation is seen as an important part of the process. Methods are suggested and contraindications to sterilization are listed (Elias, 1991). It is also clear that in many situations counselling in any true sense of the word is honoured in its absence. Perhaps this is because there is a feeling that it will be impossible to elicit any information that the patient is unwilling to share at interview.

Several members of the Institute of Psychosexual Medicine have studied aspects of counselling for sterilization and have discussed their findings. A summary is to be found in Tunnadine (1982). This author identified guidelines which include the fact that the couple seeking sterilization should have a good relationship and sex life, that both partners should wish for the procedure and that their expectations should be realistic. This group of widely experienced doctors emphasized the dangers of performing a sterilization at a time of emotional crisis. On occasions, considerable expertise may be needed on the part of the counsellor to avoid this. Their skills can be developed during seminar training organized by the Institute of Psychosexual Medicine.

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Akhtar lived with her elderly parents, and her son and daughter-in-law, and the appearances of the household indicated a traditional Hindu family. A visit concerning back pain allowed the GP to observe the packet of contraceptive pills by Akhtar’s bed. As they had not been prescribed by the GP, and as she had thought that Akhtar was divorced, she checked with the patient that they were in fact hers. During another consultation the doctor felt confused about the way in which Akhtar talked about her family. This confusion was voiced, and although Akhtar at first tried to maintain that she was married, she subsequently revealed her rather miserable life as the downtrodden mistress of an English colleague at work. Her UK-born daughter-in-law who had, perhaps surprisingly in view of her mother’s emancipation, married by arrangement, found no difficulty choosing the diaphragm as the most sensible contraception for spacing her pregnancies, despite the doctor’s idea that Hindu ritual would prohibit touching the perineum.

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In the majority of states that have sexual psychopath laws the individual must be convicted of some offense, usually but not necessarily a sex offense, before he is subject to examination. In seven states an arrest alone suffices as ground for examination. In four other states the statutes are so vague that apparently a person could be examined and adjudged to be a sexual psychopath without being charged with a specific misdemeanor or felony.”

While the laws have had considerable popularity, they are marked primarily by their disuse. For example, in Indiana the annual number of persons judged sexual psychopaths can be counted with the fingers of one hand. Some of the disuse may be attributed to inertia and some to the disinclination of the offender to request an examination which might stigmatize him as being “crazy,” but some seems to be a reluctance arising from basic legal concerns. There is in the minds of many attorneys the question of double jeopardy, since in many jurisdictions the sexual psychopaths after incarceration and treatment are returned to court where they may, at the judge’s discretion, be sentenced to prison on the basis of the original charge. To put it simply, a man may be convicted, judged a sexual psychopath, locked up for months or years during treatment, returned to court as “cured,” and then imprisoned to begin a sentence for his offense. In addition to this matter of double jeopardy, some legal scholars feel that the reports of clinicians and therapists derived from conversations with the man examined constitute a form of self-incrimination.

One state, California, has made extensive use of the sexual psychopath statute, and it is from this state that we have derived nearly all our data regarding persons labeled sexual psychopaths. In California after a person has been convicted of an offense (either misdemeanor or felony), that person, his attorney, the prosecutor, or certain other persons involved in the case may request that the offender be examined for sexual psychopathy. The judge may then appoint two psychiatrists who examine the offender, generally in jail, and report to the judge whether or not there is evidence of sexual psychopathy. On the basis of this report the judge then decides either to sentence the offender or send him to an institution for a 90-day observation period during which it will be determined whether he is a sexual psychopath an whether he is amenable to treatment. If the man is judged to be not a sexual psychopath or if he is judged to be a sexual psychopath but not amenable to treatment, he is returned to court for ordinary sentencing.

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Alcohol. The drug and alcohol histories of the men we interviewed have been discussed earlier, and it was pointed out that alcohol was definitely not a minor consideration. At this point the problem can be explored further and given a sharper focus by examining the individual offenses and recording the degree of alcohol use at the time. Table 142 indicates the percentage of offenses that were committed when the offender had had little to drink, and those in which he was classed as intoxicated. The present definitions for these two categories are as follows. If a man had one or two ounces of alcohol, it is considered that he was probably not recognizably intoxicated, although his behavior may have been influenced by a loosening of controls. This is classed as “alcohol present.” On the other hand, any degree of recognizable intoxication was tabulated as “offender drunk” at the time of offense. This is a very rough categorization, but considering the confusion of terminology which can be applied to degrees of intoxication it seemed advisable to make a simple dichotomy. These data were drawn both from the police and court records as well as from the account of the offense provided by the subject during the interview. Since recognizable intoxication at the time of a sex offense is likely to be a matter of official concern and hence invariably recorded in the police and court records, the data are somewhat weighted in the direction of positive records.

For offenses for which alcohol data were not available from either official records or interview, answers to standard questions about the offender’s general drinking habits provided a secondary source of information. In the cases of nondrinkers we assumed that there had been no drinking associated with the offense. On the other hand, the offenses committed by men with admitted drinking patterns for which data were similarly deficient were put into the “no data” category. Such an interpretation probably minimized the role of alcohol, and percentages calculated on a base of known cases only might have further distorted the picture. For this reason percentages were calculated on both known and total cases as a check. The extent to which alcohol accompanied aggressions vs. children is the most striking figure in the table. It is involved to a marked degree in two thirds of the cases, and to some degree in an additional tenth of the data-known cases. No other group approximates this level, and this generalization also holds true when the percentages are calculated with the total N as a base instead of the “data-available” cases. Next to this group comes another aggression group, that against adult females, with two fifths of the cases showing a strong alcoholic involvement. From the peak of these two groups there is a drop to a cluster of seven types of offenses in which the factor of intoxication ranged from 20 to 30 per cent. This includes the three incest groups, the remaining aggression-offense category (that vs. minors), the exhibitionists, and the heterosexual and homosexual pedophilic offenses. At the lower extreme of about 9 per cent are the heterosexual offenses against minors and adults, and just above them, the homosexual offenses involving adults and minors. Thus we can observe here a clear-cut picture: drunkenness is a greater factor in the more aberrant crimes, such as those that involve children or the use of force.

In scanning the figures on marginal drinking it can be noted that while they stay at a fairly steady level—3 to 15 per cent—the bracket of offenses in which they range the highest is again the force offenses, adding weight to the interpretation already presented.

Drugs. Turning to the degree of drug usage at the time of the offense, presented in Table 143, one sees a very different picture. The findings are clearly minimal, and the small percentages stand for a total of only 22 cases out of a total of 2,022 offenses with data available. Four of these involved the use of heavy drugs such as heroin or morphine; in ten instances light drugs such as dexedrine or benzedrine were employed, and a final eight cases involved marijuana. On an overall basis this represents very slightly over 1 per cent of the total offenses, and the only points at which this low general average is exceeded is in the 2 per cent incidence of the use of marijuana in the aggressions against adults and the 6.4 per cent usage of light drugs in the incest offenses vs. minors.

In short, unlike alcohol, drugs are a. minor factor in the commission of sex offenses.

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Homosexuality in the physically mature male has, in Western culture, been one of the most hidden aspects of human sexual behavior. Only in the last decade or so has it been considered an area for respectable scientific investigation. Now that the barriers have been somewhat lowered and more factual data on such behavior are being accumulated, the presence and extent of some homosexual elements in almost every walk of life is gradually being recognized. Exactly how broad the incidence is in this or that segment of the population is still a moot point, but certain facts have become clear.

Many males with strong homosexual preferences have been able to follow their inclinations and at the same time to keep free of legal entanglements.

The idea that persons with homosexual preferences are “sick,” “abnormal,” or “perverted” has been severely challenged from many sources, and the fact that many homosexuals are able to live useful, well-adjusted lives seems evident.

To a large extent the problems that homosexuals face arise fom the social stigma attached to this form of sexual behavior and from the homosexuals’ resulting alienation from the main stream of heterosexual society.

The fact that homosexual experimentation occurs most widely in early postpubescence and that a few isolated experiences at that time are typical of many otherwise heterosexually oriented males is now also commonly admitted. That some of these males are led into more extensive activity and that in turn a few of them become exclusively homosexual is an evident fact. Others may have only an intermittent interest in homosexual relations and may alternate between sexual contacts with males and with females.

Homosexual acts are defined here as physical contacts between two persons of the same sex, designed (by at least one of them) to produce sexual arousal and recognized by both as being sexually motivated. Latent or unconscious expressions which might be interpreted as homosexual in nature are not under consideration at this time. Overt homosexual behavior may be some form of petting such as unilateral or mutual masturbation (usually manual). More commonly it consists of fellation (either in the active or passive role) or anal intercourse. There is general recognition that being deprived of heterosexual opportunities, for instance during imprisonment, may bring forth homosexual activity that otherwise would not have occurred. For this reason we have ordinarily excluded from our tabulations any homosexual acts that took place in prison.

As is true of most human conduct, the significance of homosexual behavior depends upon its extent and its context. In one person it may be incidental and transitory, in another it may represent a lifetime pattern. In one man homosexuality may exist harmoniously with heterosexuality, whereas in another it may reflect an inability to deal with adult heterosexual relationships. Thus homosexuality should always be viewed relatively, in terms of the role it plays in the total life picture. In this chapter we shall attempt to gain such a viewpoint.

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The great majority of males fantasy while masturbating although they may not fantasy on every occasion. Males who have never had fantasies during masturbation are relatively uncommon. A tabulation of those who make this claim indicates that the control group, the peepers, and the nonforce heterosexual offenders against postpubertal females tend to fantasy least; from 11 to 18 per cent of these groups reported never having fantasied. Aside from the control group, these groups all contain relatively large proportions of persons rated as having inferior intelligence. The heterosexual aggressors were the most fantasy-prone; and the remaining groups, including the prison group, are intermediate.

More important than whether fantasy did or did not occur is the question of fantasy content. While it is true that, broadly speaking, fantasy accords with the individual’s overt experience, it does embody a great deal of wish fulfillment that often exceeds the actual experience. Thus an average heterosexual male will fantasy coitus, which he has experienced, but he may also fantasy coitus in some group activity, say with famous Hollywood actresses—something he has not experienced. In brief, fantasy generally remains akin to experience but may be highly elaborated.

On the other hand, in certain individuals a repressed desire that has never permitted overt expression is a prime theme for a fantasy. This makes fantasy a most useful psychological tool for research purposes.

In our interviews, fantasy during masturbation was covered in only a crude fashion. Furthermore, the subject was not routinely covered until after 1942. Consequently it is possible to construct only five categories of fantasy content: heterosexual, homosexual, sadomasochistic, sexual contact with animals, and a residual category. Taking only those individuals who reported some sort of masturbatory fantasy, we have calculated the percentages of individuals with the five categories of fantasy just mentioned.

Essentially all (99-100 per cent) the men in all groups except the prison and homosexual offenders had had heterosexual fantasies. For the prison group, because of a strong homosexual subgroup, the percentage was only 95. The homosexual offenders had percentages ranging from 61 (the homosexual offenders vs. adults) to 90.

In homosexual fantasy, as one would expect, the three homosexual-offender groups exceed all others by far (69-91 per cent). Moreover, they are nicely arranged in order of the strength of their homosexual orientation. The prison group occupies fourth rank with a substantial 35 per cent having had homosexual fantasy, a percentage double that of the fifth-ranking group. This homosexual emphasis among the prison group reflects their actual experience. One cannot wholly explain this high percentage of homosexual fantasy and homosexual experience by saying that it is a by-product of incarceration, since the prison group showed the same proclivity toward homosexual activity prior to puberty. Those with the least amount of homosexual fantasy (0-6 per cent) are the three incest-offender groups, and the control group also occupies a low position.

Fantasy of sadistic or masochistic situations was commonest among the heterosexual aggressors vs. minors (17 per cent) and aggressors vs. adults (9 per cent). The fact that not one of the heterosexual aggressors vs. children reported this sort of fantasy does not spoil this picture since they seem to be primarily deteriorated seniles and/or alcoholics whose behavior is more disorganized than motivated by sadistic impulses. In addition, we feel that they were more likely than other offenders to deny or erroneously report certain circumstances connected with their offenses. The control group and the heterosexual offenders vs. minors and adults had few members with sadomasochistic fantasies—a noteworthy fact, since these three groups would be considered by the layman as the three most normal.” The prison group is intermediate.

Fantasy of sexual activity with animals is equally uncommon, but scarcely a rarity. The rank-order of percentages of those with this type of fantasy is rather puzzling. First of all, the tripartite groups occur not all together, but tend to be in pairs: two of the heterosexual-aggressor groups occupy the two lowest ranks; two of the homosexual groups are adjacent in the low area; and two of the incest-offender groups are adjacent in the intermediate area. In the case of all but the incest offenders, the aberrant third group is the group whose offenses involved children under twelve. These pedophiles tend to have more members with zoophilic fantasies than their brother offenders against older individuals. Young children, like animals, are relatively vulnerable. In the case of the incest offenders, conversely, it is the incest offender vs. adults who ranks highest. This we feel has a simple explanation. The incest offenders vs. adults are our most rural group; 48 per cent had spent their formative years in rural surroundings and 12 per cent had always been rural; no other group matches these figures. The fact that they had relatively little actual sexual contact with animals is of no consequence, for in fantasy the wish is in many ways more important than the deed, especially in a group as sexually restrained as the incest offenders vs. adults. The wish, however, can scarcely have been too strong, for none of them reported dreams of animal contact.

Secondly, the peepers head the rank-order of those: who had animal fantasies (11 per cent). No rural life can explain this, since they are a strongly urban group. Furthermore, no especial tendency toward zoophilia is evident in their dream content or in their overt behavior. Yet despite a lack of objective evidence, it seems somehow logical to suppose that those who are strongly voyeuristic would obtain gratification from observing sexual activity not only in humans but also among other animals, and that this interest in animal activity might engender similar fantasy.

Our last category of fantasy—”other” or residual (i.e., a catchall category)—provides more information than one might suppose. Classed as “other” are fantasies of exhibition, hence the exhibitionists head the rank-order with 26 per cent. Fantasy of peeping explains the second rank position of the peepers. The tendency for the incest offenders and the offenders against children under twelve to concentrate in the upper half of the rank-order is the result of our classifying as “other” any fantasies of sexual contact with young children or with close relatives.

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