Hopefully, this chapter has shown how radically doctors’ consultations nowadays should differ from those of, say, 50 years ago. It seems that the fundamental elements are setting aside the illness/diagnosis model with its direct questions about bodily systems and adopting a patient-centred counselling style with its associated intuitive component. In this way doctors can not only elicit the real reasons why a patient is consulting them, but work out solutions together. By tackling problems at a deeper level doctors can learn from the relationships with their patients and help them to apply this understanding to other relationships. The doctor can then truly be said to be fulfilling his or her role as teacher, as the derivation of the word doctor implies.

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Other patients have difficulty seeing themselves as sexual once they become parents. They cannot imagine their own parents behaving sexually (although intellectually they know they must have done so), and have problems re-establishing sexual activity for pleasure after delivery. The emotional demands a new baby makes on the mother, and the intense bonding that occurs, the physical tiredness, the hormonal changes and even depression, all conspire to exclude the husband and diminish the wife’s desire for closeness with him. Some mothers may even say they do not need birth control, and not use it or refuse intercourse until they want to become pregnant again. For some, motherhood is the only role in which they feel fulfilled.

*315/197/1*

It was clear that this patient had moved on and was beginning to look forward to being freer and to doing different things with her life. Hopefully her sexual life will return, too, when she can value it again for itself rather than as a means to a pregnancy.

For some women it is not so much the loss of future babies that is the underlying sadness, but a more general sense that the end of the ability to be a fertile woman is the end of a central part of herself, something which is in some way the essence of her being.

Listening to such accounts one can understand the power of myth and legend that is handed down from generation to generation. Perhaps this is where the art of medicine comes in, to demystify and clarify.

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In the second half of the twentieth century, sterilization has become a very popular method of contraception. Worldwide in excess of 60 million women have been sterilized (Elias, 1991), and it is reported from the USA that 640000 tubal sterilizations were undertaken there in 1987 alone (Schwartz, Wingo, Antarsh et al., 1991). In the UK in 1980, one in three couples chose this method of contraception, and in 1983 it is reported that 90000 women and equal numbers of men were sterilized, at least a fifth of the women being under 30 years old. It seems likely that the forecast made in 1974, that in time one in three couples would rely on sterilization by the age of 35, will come true (Wellings, 1986).

At present, sterilization is undertaken once a family is complete, although previously the procedure was used for eugenic reasons. Even now, it is a very potent method of population control and is used as such in some parts of the world. At first the number of female sterilizations rose more quickly than those for vasectomy because of the legal doubts over vasectomy, but the numbers of operations are now more equal. The UK government has given financial support to a policy of sterilization in suitable cases, and the success of this policy has obvious long-term implications for the provision of contraceptive services (Allen, 1981). The popularity of the programme is such that it may become necessary to move resources from GP and community provision of family planning to the provision of sterilization and vasectomy.

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Feelings were explored and some practical difficulties uncovered. Due to the loss of his leg he felt unbalanced and wobbly when they tried to make love, as they always used the missionary position. When the doctor asked him why he had to do it in that position he was amazed and said he had never thought of doing it any other way. This led to a discussion of other positions and options. It was necessary to consider how he would feel if he was in the underneath position as he already felt ‘flattened’. There had been no real communication with his wife about his doubts and fears. He felt she did not want to upset him, and she tended to say things like, ‘It’s all right, don’t worry about it.’ He felt ashamed of the sexual difficulty, and of the loss of his limb, hoping that when he limped people would think he had a touch of arthritis. There was a need to grieve for all the losses.

Following this meeting with the doctor, Alan was able to talk to his wife at length, and he felt they could now share the problem. He had a smile on his face as he said that they had experimented with new positions and that it was now fine and there were no problems.

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Shifting attention now to the offenses in which physical contact occurred, and examining first the heterosexual offenses, the obvious distinction is between offenses in which coitus occurred or was attempted, and those in which it did not occur or was not attempted. (Coitus here, as before, is defined as penile penetration, at least partial, of the vaginal orifice.)

As might be anticipated, the proportion of offenses in which coitus was reported became greater with the increasing age of the female. This held true, but to varying degrees, among the nonaggression and aggression cases, as well as among the father-daughter incest offenses.

In all three offense types it is clear that the sharpest increase in the proportions of completed coitus occurred in the offenses with minors when compared to those involving children. The offenses with adult females tend to show the highest percentages, the exception being the group in which force was used. Here there was doubtless a strong factor of ability to resist as well as increased experience entering into the picture which in some of-the cases may have prevented the coitus. This can be inferred from the high percentage of the instances in which coitus was attempted but not completed. If the figures representing attempted coitus are added in and the total percentages taken as a measure, the pattern of an increase in coital behavior with an increase in age-of-object is more consistent with that shown in the other categories. The failure of the cases of attempted coitus with children is doubtless accounted for not So much by the child’s resistance as by the offender’s inability to enter the immature vagina.

A second observation is that with adult objects there is a much higher degree of coitus in the voluntary eases than in those in which force was employed, and a still greater degree in the incest cases. This is true whether or not the attempts at coitus that were not completed are included. The same is true in the offenses vs. minors, but to a somewhat lesser degree. On the other hand, where young children were concerned there was a small amount of coitus in the nonforce cases, a somewhat higher level in the incest cases, and the highest percentage (constituting almost a fourth) in the aggression cases. In short, in the present sample sexual contacts with children are more likely to consist of completed coitus when force is used than when it is not. The opposite holds true for minors or adults, since coitus in these cases is completed much more often in the consenting relationships.

This is of note particularly in the cases vs. children in which one might have assumed the opposite results. In fact, the use of force in some instances was the very element that led to the termination and disclosure of the incest relationship. Since force must be discounted, one is tempted to seek other explanations for the comparatively high level of coital behavior in all three incest groups. The most likely factor appears to be the one of frequent opportunity. The typically long-term aspect of incestuous relationships probably allows and even promotes a degree of sexual intimacy which is not found in the parallel heterosexual nonforce groups.

When attention is focused on the remaining heterosexual offenses in which there was physical contact, but no coitus or attempted coitus, a varied pattern is found. Since coital activity occurred least often in the groups with the youngest objects, it is here particularly that the most extensive use of petting techniques as a sex offense is reported. In the heterosexual offenses against children a fourth consisted of simple or nongenital petting, a half of genital petting, and an additional sixth of mouth-genital contacts, altogether accounting for well over 90 per cent of these offenses. Among the aggression offenses it is also in the youngest age group that by far the highest incidence of petting as the offense behavior is reported, but here it totals somewhat less than half of the cases. Nongenital petting accounts for less than 10 per cent, and genital petting and mouth-genital contacts are each reported in about a fifth of the offenses. In the father-daughter incest cases we find again that among the youngest group petting is the primary behavior in the offense. In this group it is understandable that there is only a single case with a report of nongenital petting as final behavior in the offense, since this is not likely to be cause for complaint between a father and a young daughter. But more elaborate petting was the basis of the charge in four fifths of the 69 cases in this group, about equally divided between genital petting and mouth-genital contacts, either cunnilingus or fellation. Thus, while these three kinds of offenses involving children all show a high amount of petting as offense behavior in comparison to offenses vs. older objects, there is a marked difference in the degree. Heterosexual pedophilic offenses rank highest, incest about 10 per cent lower, and force offenses by far the lowest.

The large number of instances in which nothing more than nongenital or simple petting took place in the nonforce offenses against children suggests how easy it is to run afoul of the law with very young girls, whereas the same activity with minors or adults might well be ignored or laughed at, unless it progressed to further stages. The fact that the incidence of nongenital petting as offense behavior in this category is so far in excess of the small percentages found in aggression and incest cases involving children can probably be explained in the following way. In the force cases the aggression factor soon pushed the activity beyond this limit, while in the incest cases simple petting alone could scarcely be a basis for charges. Furthermore, the combination of opportunity, family intimacy, and authority on the part of the father provides a favorable atmosphere in which to further the sexual exploitation of the child.

While in the nonaggression, aggression, and incest offenses against minor girls the same three degrees of petting occur, they assume less importance, as coitus and attempted coitus play a larger role. Petting with adult females is still less often the chargeable offense. In fact, the incidence of petting as final behavior is recorded in about a third of the heterosexual offenses vs. minors and in only one sixth of those vs. adult women. The same two groups (i.e., vs. minors and vs. adults) in the incest cases reported a fourth to less than a tenth. This relationship holds true for the heterosexual cases involving force, as the percentage with charges based on petting activity, which stands at nearly half for the offenses against children, drops to about a quarter and further to a sixth for the next two older groups.

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One of the major concerns of many persons has been the connection between sexuality and violence. A canon of the post-Freudian psychologies has been that suppression of sexuality may cause an outcropping of violence and sadism. A literary parallel is the allegedly puritan era of Queen Victoria and the concomitant flowering of sadomasochistic erotica. Today such literary and graphic forms as paperback novels, comic books, and television programs exploit violence as a means of entertainment, and many persons are concerned lest these influence the youthful reader or viewer toward similar behavior, or at least cause an insensitivity to the suffering of others.

In the early phase of our research questions concerning sadomasochism were not routinely asked. Later every person was queried about whether he was sexually aroused by seeing pictures of, or reading about, rape, flagellation, torture, and violence in general.

Half of our 16 major comparative groups, including both the control and prison groups, had over 90 per cent of their members who reported never having been sexually aroused by such noncontact sadomasochistic stimuli, and another four groups gave essentially the same figure (89 per cent). The remaining four groups contain the three aggressor groups: the aggressors vs. children (88 per cent), vs. adults (85 per cent), and vs. minors (79 per cent). The range of response among all groups is so small that the only significant finding is the clustering of these aggressors in the lower quarter of the range.

In examining degree of response to sadomasochistic noncontact stimuli, one is struck by the fact that in 11 of the 16 groups the same or nearly the same percentages of individuals within a group reported moderate and strong responses. This is curious, for with a stimulus to which the great majority have no response one would expect those with a moderate response to outnumber those with a strong one. This expectation is fulfilled in only three groups, including two of the aggressor groups. In the remaining two groups, including one aggressor group, the strong responses outnumber the moderate. What this equivalence between moderate and strong response in most groups means, and why the three aggressor groups lack this equivalence, is not known.

Of the sex offenders whose offenses included violence or duress, between one eighth and one fifth reported arousal from sadomasochistic noncontact stimuli. While it is probable that in a few cases such stimuli triggered an offense, it seems reasonable to believe that they do not play an important role in the precipitation of sex offenses in general, and at most only a minor role in sex offenses involving violence.

There is a rather disappointing lack of correlation between arousal from noncontact sadomasochistic stimuli and the content of dreams and masturbatory fantasy. In part this may reflect the haste with which we covered the latter two subjects; more probing might well have unearthed data resulting in a high positive correlation. At any rate, there are only two noteworthy coincidences: more aggressors vs. adults had sadomasochistic dreams than any other group, and they and the aggressors vs. minors head the list of those with sadomasochistic masturbatory fantasy.

*339\161\2*

Since coital incest occurs chiefly before marriage, we shall treat it in this chapter. Coital incest is defined as coitus had by a postpubertal male with a female whom he could not marry because of her familial

relationship (genetic or social) to him. All persons interviewed were asked concerning incestuous coitus; unfortunately, we did not inquire about petting without coitus. Under incest we have included coitus between first cousins, since most states prohibit first-cousin marriages. We have departed from the above definition by considering as incest coitus with a sister-in-law, an act which most individuals regard as close to, if not actually, incest, despite the fact that one can marry an ex-sister-in-law. It is curious that despite Biblical exhortations, marrying a former sister-in-law is often frowned upon—particularly if divorce rather than death made the marriage possible.

Incestuous behavior is commonest with first cousins and least common with mothers. The sequence is: first cousin, sister, aunt, sister-in-law, then (almost equal), niece and daughter, and lastly, mother. Note the commonest four relatives are those apt to be near the subject’s age; an aunt who is one’s peer is not uncommon, particularly in the lower socioeconomic stratum. The frequency of sister incest may be explained by the combination of proximity and very early coitus; brother-sister incest is almost invariably at a young age and seems essentially a carry-over from prepubertal sex play. Incest with grandmother and granddaughter has been omitted from the list above because almost no cases of coitus exist in our sample.

Aside from the obvious statement that coital incest, as defined above, is most prevalent among the incest offenders vs. adults and minors, little can be said. Due primarily to the ages of their daughters or stepdaughters, coital incest is uncommon among the incest offenders vs. children. The reader will recall that coitus is not a requisite in the definition of incest offenders. Except for first-cousin incest, incest is such a minority phenomenon that any generalizations are reduced to the status of near speculation. Nevertheless, it is clear that the prison group and the sex offenders as a whole far exceed the control group in incestuous behavior. Lastly, the heterosexual aggressors appear to be the most incest-prone of any group except for the incest offenders. All three aggressor groups have over one eighth of their members with incestuous coitus, and consequently occupy die upper portion of the rank-order.

*301\161\2*

The question whether the sex play was heterosexual is our next concern. In compiling a rank-order of those who ever took part in heterosexual play, it again becomes obvious that the percentages involved are influenced by the average age at puberty, although not so strongly as was true for prepubertal sex play as a whole. The agreement between incidence of heterosexual play and age at puberty is rather good except that the homosexual offenders show more moderate figures despite their early puberty (their homosexuality seems to compete with heterosexuality), and two aggressor groups have larger incidence figures than their age at puberty would make one anticipate. We see that relatively few of the heterosexual (including incest) offenders against females aged twelve and over had prepubertal heterosexual play: they occupy the lower portion of the rank-order. These groups were relatively late in reaching puberty. The control and prison groups are 52 and 53 per cent, i.e., centrally located in the rank-order. The offenders against female children under twelve, the homosexual offenders, and most of die heterosexual aggressors rank higher than the control group. The first three positions are filled by groups whose members reached puberty early. However, fourth place is occupied by heterosexual aggressors vs. adults who reached puberty rather late; this, plus the fact that the heterosexual aggressors vs. minors head the rank-order, makes one feel that aggressiveness per se may be associated with prepubertal heterosexuality.

In homosexual play the three homosexual-offender groups occupy the first three ranks with percentages of from 60 to 69. Once again the control group is rather central (41 per cent), and the heterosexual offenders (including incest) against females aged twelve and older occupy the lower portion of the rank-order. Two of the heterosexual-aggressor groups are low in homosexual play whereas they were central to high rated by heterosexual play. We shall see that this is probably the result of the aggressors being more strongly oriented toward prepubertal heterosexuality than most of the other groups. The prison group, which was close to the control group in measurements of the presence or absence of prepubertal sex play and in heterosexual play, exceeds the control group in the proportion of members who had homosexual play. This is our first intimation that throughout life, pre- or postpubertal, the prison group is more homo-sexually inclined than the control group, an inclination subsequently reinforced by imprisonment. The correlation between incidence and age at puberty again exists as it did with heterosexual play (see Table 20).

Having examined the simple presence or absence of prepubertal hetero- and homosexual play, it is worthwhile to see how many individuals with sex play were exclusively heterosexual or homosexual in their sexual activity.

With regard to exclusive heterosexuality, all of those whose sex offenses were against female children are in the upper portion of the rank-order with percentages of from 25 to 36. Similarly, the heterosexual aggressors rank rather high, occupying second, third, and fourth ranks. The control group is once more centrally located with 23 per cent. The homosexual offenders occupy the bottom ranks.

Exclusively homosexual play is somewhat less common. First through third ranks are occupied by the homosexual-offender groups (20-24 per cent), the prison group is more or less central, and die control group is a bit low. Again revealing their prepubertal heterosexual orientation, two of the three heterosexual-aggressor groups occupy the lowest two ranks.

Since one lone experience suffices to place a person in a category such as “exclusively heterosexual play,” we had to get an idea of the quantity and intensity of the sex play in some other way. We therefore calculated the duration of sex play and the techniques involved.

*263\161\2*

Examination of the ages of the first coital companions of the peepers results in something of a problem. Peepers had relatively few young (fifteen years or under) coital companions, which one would anticipate since they tended to start having coitus later in life than most. But in the age-category of companions who were sixteen to seventeen they suddenly appear in first rank with an astonishing 50 per cent who had their initial coitus with girls of that age. This is in keeping with what we have seen in the accumulative incidence of premarital coitus: a sudden rise from a low rank-order position by age sixteen to an intermediate position by age eighteen. The problem arises in the next age-category of females aged eighteen to twenty, where the peepers fall to a low position in the rank-order with only 10 per cent, the same percentage they exhibited in age-category 14-15. Later, in the age-category 21+, they again achieve intermediate status.

All in all, the picture is one that we have seen before: a relatively inhibited, or at least inactive, group blossoming out in later life. This phenomenon is almost automatically insured; since the vast majority of all groups were coitally experienced, if the number of experienced persons is small earlier in life, it must of necessity radically increase later in life.

There is nothing significant in the reported age preferences of the peepers. While we did not routinely ask them the ages of the women they hoped to see, we do have the impression that they were primarily interested in females in the age-range regarded by our society as most physically attractive. Not infrequently the peepers spoke of having left their vantage points because the females were too young or too old. Pedophilia and gerontophilia are not attributes of the ordinary peepers.

*224\161\2*