*357/197/1*

Patients also provide constraints. Just because a problem is revealed does not necesarily mean that the patient wishes to do some work on it. It may not be the right time for the patient to look at the difficulty exposed, perhaps unwittingly. A patient who revealed for the first time at the age of 38 years, that she had been sexually abused as a child, because of something that had been picked up by the doctor during a routine cervical smear, did not wish to take up the doctor’s offer of another appointment or referral to discuss it further. She felt it was better left buried (as it had been for many years), despite her difficulty in responding sexually to her husband.

*318/197/1*

Most patients who request sterilization regard the decision as a private matter that they have discussed with their partner. They come to the medical profession for technical help, and in very many cases this is all they need. It is at this point that there is an opportunity for full discussion of the expectations of the two people concerned, and for obtaining a medical, obstetric and sexual history. Examination is undertaken to exclude abnormalities and disease. During this interview it should be possible to identify unrealistic fears related to contraception or either of the operations, and to make a decision as to which partner should undergo the procedure.

*242/197/1*

An important part of lovemaking is the giving of pleasure and, even if this means that it appears one-sided, to be able to see the partner experiencing sexual pleasure can be very satisfying even if there is loss of sensation to the giver. Sometimes it is difficult for the partner to accept such one-sided pleasure, but if it is what they both want, then she/he may be able to be helped to do so. After sharing the loss and grieving for it, some people are able to fantasize and recall in the mind the sensations of the past.

*204/197/1*

In none of the nine groups of offenses was force evidenced in more than about one eighth of the cases, or threat in more than about one sixth. Both of these top ranges appear in the incest groups. Homosexual offenses in general show a much lower incidence of force or threat, and as would be expected the already weeded-out heterosexual non-force offenses have the lowest figures. Force is more often employed against children in both the heterosexual and homosexual offense groups than it is against minors or adults. Only in the incest cases does it appear equally in the three age groups. Threat is a much less important element than force among all these offense groups, except in the incest offenses, and here parental authority undoubtedly lends considerable weight.

Examining first the nonaggression offenses in which some degree of force appeared, we find that in the 11 heterosexual offenses vs. children which represent the 4 per cent with minor force there are instances of such action as pushing, grabbing by the arm, pulling down of panties, attempting to undress, and of lying on top. In some of these cases the report is conflicting so that it was difficult to get a clear picture of what actually occurred and of the degree of aggression involved. In one case the offender’s wife held the girl for him (both were drunk), in another the girl was knocked down in a general melee, but apparently without sexual intentions, and in several of the instances the tentative aggression might have become more violent if the child had not run away or if the offender had not been frightened off by her shouts. While these offenses did not portray cooperation by the child in any sense of the word, neither did they seem to merit being classed with the aggression offenses, since most of the marginally aggressive behavior occurred as a preliminary before any sexual activity took place. Such intentions may have been definitely implied, however.

The single case of marginal force in an offense involving a minor female presents a description of roughhousing with a fifteen-year-old baby sitter who evidently provoked it by tickling the offender first. He then pushed her into the bedroom, held her on the bed, spanked her, and “pushed her bloomers to one side.” This was done in the presence of the children. The girl first complained ten days later following an argument with the offender’s wife.

The three cases of minor force in offenses vs. adult females represented by the figure of 1.4 per cent included an incident of slapping a girl during the preliminaries to coitus because she was too noisy, of holding a hand over a girl’s mouth prior to having coitus in a car, and of a fruit peddler in an apartment house who “made advances” to a sixteen-year-old who screamed and scared him away.

When considering force or threat as related to incest, one must recall that these offenses differ from all others because of the father’s unique position of authority. Given then this special paternal prerogative of a high degree of control over one’s offspring, the question arises as to the extent to which force and threat are needed in attaining intimate sexual contact. It will be recalled that the use of force and threat in incest was found to be unrelated to the kind of sexual techniques used.

Inspecting the histories to survey the form that the violence took, one finds in the offenses vs. child daughters accounts of spankings, slapping, and beating, in two cases with some physical damage. Threats were usually used to try to prevent the child from reporting the incest, and ranged from menacing her with whipping or spanking to threatening to kill her and her mother (one case) or to break up the family with a divorce. In the cases of force or threat against minor daughters, the girl’s resistance doubtless became more marked, and as a result the force more violent. Reported behavior of the father here included slapping and knocking down, choking, beating with a belt buckle, pulling hair, and two cases of the use of drugs to minimize resistance. It also includes threats to make her wash dishes and to deny her TV viewing. Other more serious threats were “to beat up her mother,” to administer a beating with a leather strap, and to kill her and her mother (three cases). That these latter were not idle threats made only to gain a sexual end is evidenced by the fact that in one of these cases such a threat was actually carried out when the prisoner escaped following the incest conviction.

Finally, the five instances of force or threat reported against adult daughters actually represent only three offenses since the two threat cases overlap with those in which force is involved. As might be expected these instances also show strong forms of violence and involve in one case a revolver and leather strap, in another a knife, and in a third assaultive battery with resulting physical injury.

Thus it appears that while force is not a very frequent occurrence in incest offenses, it is likely to take a more severe form the older the daughter becomes, and also that parental threat is especially evident in the incest offenses vs. minors.

Turning now to the homosexual-offense groups, one finds that the 10 per cent incidence of force against children represents a total of 12 cases, which when inspected for details of the aggressive behavior fall into several groups. The largest is a group in which force was used to coerce a boy into sexual activity, usually fellating him. This covers seven cases and typically involved choking, striking, or pushing and holding by a considerably older male. One object was a stepson, another the son of a friend; others were strangers.

Second is a small group in which the force seemed to follow as a result of fright usually caused by the boy’s cries from fear or pain. Typical was the case of an eighteen-year-old sailor, AWOL, who met two boys aged nine and twelve who were fishing. The nine-year-old was an apparently willing partner at first, but when they went behind some brush, anal intercourse proved too painful for the boy, and he screamed. The sailor, frightened, hit him and ran, losing his ID card, which led to his arrest two weeks later.

Third are several cases that might be described as resulting from ineptitude, in which the male seeking homosexual contact blundered into force through lack of comprehension of the situation. In one case a man with defective speech and an IQ estimated between 55-75 asked a four-year-old boy to expose his penis, and then tried to hold him when he started to run away. Another illustration is a sixteen-year-old male, who because he had originally achieved his first erotic arousal by accidently touching a boy’s legs, knew of only this way to obtain gratification. He took a seven-year-old boy behind some bushes in his yard to wrestle so he could touch his legs. The boy was frightened and screamed, and the offender struck him. While in some of these cases the child was definitely mistreated, truly sadistic behavior is recognizable in only one case of homosexual pedophilia. This was a forty-eight-year-old male who picked up an eleven-year-old boy in a movie and kept him for a week in his room. He whipped him for getting too close to the window and admitted he received “pleasurable excitement” from it, although he claimed he was not sexually aroused at the time.

There are also three cases of threat against young boys. One is an overlap with a force case described earlier; in a second, the man was accused by an eleven-year-old Mexican boy of forcing a mouth-genital contact at gun point, but denied the offense; and the third case was that of a thirty-five-year-old offender who told his six-year-old nephew that if he did not give in to his homosexual demands he would “dig a hole and put you in it like those septic tank holes.”

When one examines the homosexual offenses vs. minors in which the incidence of force drops to 4 per cent and threat to 1.6 per cent, the general picture is much the same except that none of the boys appear to be previously known to the offender. In two cases newsboys were picked up; the others are chance contacts also. As to the form of the aggression, typical are two “forced into cars,” one slapped after refusing to perform what he had promised upon payment of $2.50; a third, a fifteen-year-old, forced into foliation in a gas-station toilet by a drunken twenty-five-year-old offender; and finally a twelve-year-old ordered to lie face down in the park grass plot and slapped when he refused. Threats consisted of brandishing a knife in two cases, one of which was also included above, and an approach in a theater in which the offender threatened to “smack” the boy if he did not keep quiet.

In the final group of homosexual offenses, those with adults, one finds the lowest incidence of force, 2 per cent, representing six cases. Adult homosexual relationships are largely consenting; if not, they tend to be interrupted prior to a completed sexual act. No threat cases appear here. Two of the cases occurred in the prison “tank” in a large city. A pair of “buddies” were accused of demanding homosexual favors for protection from other prisoners and helped each other to force the object to comply with anal, intercourse and fellation. Two of the remaining four cases arc accounted for by an older hobo who was accused twice of dragging a teen-age boy to a railroad culvert in a city to try to gain a homosexual contact, and the last two cases are for minor aggressive acts. None of the six eases seemed to include sadistic acts for their own pleasure, but the force was an integral part of obtaining the desired homosexual connection.

It is clear that these few cases represent only a sporadic sort of phenomenon and cannot be considered as showing a trend in the almost 300 offenses vs. adult males under consideration. In these examples of violence there appears to be a tendency for the offense to occur within a hobo, prison, or prostitute context. The homosexual contacts of this character vary considerably from the usual homosexual relationships.

It must be added that violence, and of an extreme kind, does sometimes occur within the framework of homosexual relations. This is evidenced by the startling fact that two of the homosexual offenses vs. adults resulted in murders, among the few in the present total sample. In neither case, however, did the murder occur during a forcing of homosexual relations, but rather as an explosive aftermath. Thus by our present definition the violence cannot be considered as part of the developmental circumstances of the sex offense proper. One case involved a fifty-five-year-old victim, a prosperous banker, and the second a casual acquaintance and both were stabbed to death.

*380\161\2*

Nearly one quarter of the prison group had juvenile criminal records. Only two offender groups exceed this figure and only two more approximate it; otherwise the sex offenders have only 7 to 14 per cent with records of juvenile crime. Two of the three aggressor groups had percentages essentially equaling or surpassing the 24 per cent figure of the prison group.1 They and the peepers seem the only sex offenders prone to juvenile court trouble.

The seriousness of the juvenile criminality, in the eyes of the community, may be measured by the percentage of boys who were committed to a juvenile institution for a period of six months or more. We again see the same picture that was presented by juvenile criminality as a whole: the prison group, with 16 per cent, is exceeded by the same two sex-offender groups and roughly equaled by two others. By and large, half to two thirds of the boys with juvenile records were commit ted for six months or more, but there are three exceptions to this generalization. Four fifths or more of the offenders vs. adults, the homosexual offenders vs. minors, and the homosexual offenders vs. adults had six-month-plus commitments. These groups are not notable for adult criminality; in fact the heterosexual offenders vs. adults had the smallest number of felony convictions per capita of any group.

Juvenile convictions for a sex offense range from none to nearly one fifth. The 2 per cent figure of the prison group is exceeded by about half of the sex-offender groups, but of these only four had more than 6 per cent who had committed juvenile sex offenses. These are the aggressors vs. minors (18 per cent), the homosexual offenders vs. children (10 per cent), the homosexual offenders vs. minors (7 per cent), and the peepers (11 per cent) ,2

The kinds of juvenile sex offenses have a direct relevance to the sex offenses committed by these individuals as adults. The heterosexual offenders, even as boys, had their juvenile sex offenses involve females. An even clearer relationship exists among the homosexual offenders. Of the ten males among the homosexual offenders vs. children who committed juvenile sex offenses, nine committed homosexual offenses. Among the homosexual offenders vs. minors, ten had juvenile sex offenses of which eight were homosexual, and among the homosexual offenders vs. adults the proportion is three out of four. Half the peepers and exhibitionists were committed as boys for peeping and exhibition respectively. The heterosexual aggressors lack this relationship between the type of juvenile and adult sex offense.

In all but three groups the percentage with nonsexual juvenile convictions outweighs by a wide margin the percentage with sexual convictions. These three exceptional groups are the homosexual offenders vs. children and minors, and the heterosexual offenders vs. children: here the juvenile sex-offense figures are more than half those of the juvenile nonsex-offense percentages.

*342\161\2*

The fourth decade of life reveals the ultimate marital picture. Aside from the incest offenders, the three groups that one might term our sexually most “normal”—the control group, the prison group, and the offenders vs. adults—had the largest proportions of ever-married men, all with over four fifths of their members married (see Table 66). In contrast, the homosexual offenders never attain the two-thirds mark and the exhibitionists barely do so. Our sample of peepers is too young and too small for calculation in this span of life, but if their prior percentages are any clue, they too would have relatively very few married. In brief, it appears that those groups characterized by difficulty in heterosexual adjustment—the homosexuals, exhibitionists, and peepers —have the fewest men who ever marry.

*304\161\2*

A similar picture is seen when one makes a rank-order of those with numerous female companions (regardless of the number of male companions). The three homosexual-offender groups head the rank-order, and the offenders and aggressors against female children again fall in the upper half.8The prison and control groups are part of an intermediate area. Few of the peepers and the incest offenders vs. adults reported numerous girl companions. There is no correlation between having had many girl companions and incidence of prepubertal heterosexual play.

The homosexual offenders’ social success with girls should surprise no one. Around age: ten there is the tendency for boys to disdain (or pretend to disdain) female companions—only “sissies” play with girls.

Taking the obverse of this picture, those who reported no female companions, we find heading the list the incest offenders vs. adults (52 per cent, by far the greatest figure) and in third rank the peepers. Any expectation of linking adult inhibition or maladjustment with the absence of girl companions in prepuberty is, however, shattered by the fact that second rank is occupied by the heterosexual offenders vs. adults and fourth rank by the heterosexual offenders vs. minors. The presence of these two groups so high in the rank-order is probably the result of the common tendency for boys nearing puberty to achieve social status by avoiding girls and claiming a distaste for them—the attitude of what one might call an active, energetic extrovert. Aside from the fact that the control group is central in the rank-order, about the only additional thing that may be said is that two of the three incest groups and two of the three homosexual groups occupy the lower portion of this rank-order—that is, relatively few of them lacked girl companions. While incidence of prepubertal heterosexual play does not correlate with having numerous girl companions, it does correlate with having none: the three groups with the lowest incidences of such play rank first, second, and fourth in the proportions of those who lacked girl companions.

*266\161\2*

The peepers had very few alcoholics among them (7 per cent, the third smallest proportion) and the largest number (23 per cent) of abstainers from alcohol.

They tended to be similarly conservative in drug use: only the control group had fewer persons who had tried or used drugs (5 per cent being the figure for the control group and 8 per cent for the peepers).

In gambling behavior the peepers tended to parallel the control group: nearly half had never gambled, about two fifths were social gamblers only, and about one eighth, a somewhat small proportion, had gambled seriously.

*227\161\2*

Treatment of people with significant risk of infection with zidovudine following an exposure to blood or other potentially infectious body fluids reduced the likelihood that they would become infected. The sooner medication was started, the more protection was offered. The current recommendation for massive exposure is to start therapy with zidovudine, 3TC, and indinavir (triple therapy) within one hour after the exposure and continue for twenty-eight days. If a person had a very-high-risk exposure and the medications were not initiated within this time frame, then in some situations they may be started later. These medications obviously have side effects, and the decision to use them must be an individual one. About one-third of those who have begun taking these medications after exposure discontinue them because of their side effects.

*337\213\8*