The highly conservative numbers in the second row derived from treatment studies of men with BPH, encompass every health problem the men reported—including problems that were not actually due to the BPH treatments. So, with that in mind, look at the figures: In most cases, complications do not occur. And even when they do, most complications are not serious. Some of them are—particularly bleeding that requires transfusion, a risk of surgery. Among the most common complications is retrograde ejaculation. This may occur in as many as 70 percent of men after TUB-, and in a few—about 7 out of 100—men on alpha blocker drugs. Some men taking alpha blockers report dizziness, tiredness and headaches. About 5 percent of men taking finasteride report some kind of sexual problem, such as a diminished sexual drive, a decrease in the amount of semen they make, or trouble achieving or maintaining an erection. Note: Although watchful waiting doesn’t carry any immediate complications, over time, symptoms may get worse or new symptoms may develop as the disease progresses and the urethral obstruction becomes more severe. Only TUR clearly reduces the risk of future problems with obstruction.

*295\201\8*

Bleeding. Bleeding after surgery can be caused by too much activity, including straining to go to the bathroom. Your doctor will probably give you a stool softener or mild laxative to make that crucial first bowel movement after surgery easier. Also, you’ll probably be advised to steer clear of aspirin and strenuous activity for the first four weeks after surgery to avoid a delayed episode ofbteeding. With the TUR procedures, there’s a lower risk than with open prostatectomy of bleeding during and after surgery that requires a transfusion. (In one study, 7 to 14 percent of men who underwent TUR needed transfusions.) Bleeding seems to be associated with the size of the prostate and duration of surgery; a larger prostate generally means more tissue to remove, and thus a longer time spent in the operating room.

The “Rollerball” Variation. In a brand new approach to TUR, surgeons use an electrocautery “rollerball” instead of the cutting loop. Overgrown tissue is vaporized, not chiseled away, so there are no leftover chips. The technique is highly promising: It appears to have minimal complications, litde bleeding, and shorter catheterization and hospital stays. And, while it offers many advantages of laser prostatectomy and other high-tech procedures, it’s far less expensive. There are many good reasons to believe the rollerball may soon become the technology of choice.

TUR Syndrome. This, too, occurs very rarely—in about 2 percent of patients. It’s caused when the body absorbs excessive amounts of the irrigating fluid used during the TUR procedure. Its symptoms are nausea, confusion, vomiting, high blood pressure, a falling heart rate, and visual problems. TUR syndrome is temporary and is quickly reversible with diuretics or a saline solution, which help restore the body’s normal fluid and mineral balance.

*256\21\8*

To recap: The keys to a normal erection are for the arteries to open and fill the penis with blood, and for the veins to close, so the blood can’t escape the penis; the smooth muscle tissue also needs to relax. Several drugs can produce erections by making these events happen. They are vasodilators; they open up blood vessels, making a wider channel for blood to go through. They also cause the smooth muscle tissue to relax and the veins to close. The main advantage here is that these drugs produce an absolutely normal erection. Some of these erection-producing drugs include papaverine, phentolamine, and prostaglandin E-1.

It usually takes less than five minutes for one of these drugs to work, and the erection can last as long as a couple of hours. It will be important for your doctor to determine the lowest possible doseyoxi need to achieve an erection; this will help reduce the risk of side effects. Other ways to help lessen side effects include limiting injections to no more than once a day, and using an insulin syringe (which has a smaller needle than many syringes) to minimize pain and bleeding from the injection. Also, men should compress the site where the needle went in for three minutes after the injection; this also helps reduce bleeding and tissue damage.

Penile injection is not for everybody. These erection-producing agents won’t help men with vascular problems. However, they do work in most patients. Because of the nature of this therapy—giving the penis a shot—it obviously is not ideal for men who can’t see well, men with poor hand-eye coordination, or men who are very overweight. Also, because many erection-producing drugs reduce blood pressure, this can cause problems for some men with heart disease.

*219\201\8*

Antiandrogens

These drugs don’t care how much LHRH, LH, FSH, testosterone, or DHT you make; it doesn’t matter to them. (Actually, antiandrogens cause testosterone levels to go up because of an increase in LH.) All they do is make sure testosterone and DHT don’t reach their targets—the receptors. In other words, antiandrogens act as dummy keys in the “locks,” or receptors. When testosterone and DHT reach the receptors, there’s already a key sitting in the lock—so they can’t enter the lock and activate the receptors. Therefore, the tumor doesn’t get the hormones it needs to nourish its androgen-dependent cells.

Flutamide is the most widely used anti-androgen. Casodex, a new, not-yet-approved drug, is another; so is cyproterone acetate, an antiandrogen that’s used in Europe but is not yet approved in this country.

Their potential advantage is that, because testosterone is not suppressed, they preserve potency. In men taking flutamide, for example, 87 percent remain potent. (This is not true, however, for cyproterone acetate. This drug, like estrogen, also suppresses the hypothalamus-pituitary connection—so it lowers LH, which affects testosterone production. Thus, it does produce impotence.)

But do antiandrogens work? The answer, for now, is probably not enough when they’re used by themselves. They also produce breast enlargement in 74 percent of the men who take them.

In total androgen blockade (see below), flutamide is given along with an LHRH agonist. In new research, scientists are looking into combining flutamide with something else—perhaps finasteride (discussed later in this chapter) to increase its effectiveness.

Side effects: Flutamide’s major side effect is diarrhea. Also, it can cause significant liver damage in some men; therefore, it’s a good idea for men taking flutamide to have their liver function checked after the first few months of treatment.

*180\201\8*

This is basically hand-to-hand combat, instead of missiles launched from far away. The idea here is that the farther away energy gets from its source—the more tissue a radiation beam has to pass through to reach its target—the less effective it will be in killing cancer. And that implanting tiny sources of radiation directly in the cancerous tissue (brachy comes from the Greek word meaning “short,” as in “a short distance away from the malignancy”) will really blast the tumor—and, as an added bonus, minimize the risk of harming innocent civilians, the cancer-free cells nearby.

The concept is not new. Pierre Curie thought of it nearly a century ago— even before external-beam radiation treatment came on the scene—and doctors in New York tried it several years later; they inserted thin glass tubes with a radioactive substance called radon directly into tumors. The treatment killed tissue, all right, but the results were uneven; some of the targeted tissue was devastated while other tissue remained unscathed. In the next decades, scientists improved the technique, but its popularity waned as hormonal treatment developed and as external-beam radiation therapy got better (see above). In the 1950s and 1960s, however, improvements in dosages and radioactive materials helped foster a comeback for interstitial therapy: Doctors implanted radioactive gold “seeds,” or tiny chunks of radioactive material, in men with prostate cancer; this was combined with external-beam radiation therapy. A few years later, doctors began using radioactive iodine seeds to fight prostate cancer.

*142\201\8*

Some 93 per cent of the homosexual offenders vs. minors had had premarital heterosexual petting experience, the median individual having had his first postpubertal experience at the rather early age of 14.9 years.

The age-specific incidence of petting after age fifteen is low: within age-period 16-20 the percentage is next to the lowest (82 per cent). It is significant that during these years the homosexual offenders occupy the three lowest positions in the rank-order of percentages. In age-period 21-25 the homosexual offenders vs. minors again have the next to lowest percentage of individuals involved in petting (80 per cent).

The accumulative incidence—the proportion with petting experience by a given age—shows a rather similar picture. By age twelve the homosexual offenders vs. minors fall in the lower part of the rank-order; by age fourteen and thereafter they occupy intermediate to low-intermediate positions.

A moderate proportion (ultimately nearly a third) of homosexual offenders vs. minors reached orgasm in premarital petting, but they did so with only moderate to low frequencies, ranging from about 6 to 10 times per year (mean frequency). One may recall that the homosexual offenders vs. children displayed even lower frequencies, but it should not be assumed that petting to orgasm is rare among homosexual offenders until the homosexual offenders vs. adults have been examined.

The age-specific incidence of petting to orgasm was moderate in all age-periods, reaching its maximum of 27 per cent in age-period 16-20 and declining to 16 per cent in age-period 31-35.

Nine per cent had no female petting partners, a figure exceeded only by two groups, the homosexual offenders vs. adults and the peepers. Examination of the percentages with various numbers of partners (one, two to five, six to ten, etc., up to 101 plus), shows that the homosexual offenders vs. minors tend to occupy middle positions in the rank-orders. The largest percentage (18 per cent) had from 11 to 20 partners, the highest modal category of any of the homosexual offenders. By and large the percentages of the homosexual offenders vs. minors are similar to those of the control group in the categories beyond two to five partners.

The heterosexual adjustment of the homosexual offenders vs. minors is something of a puzzle. We have seen that in preadolescence, at ages ten to eleven, they had an excellent socialization with girls and a relatively abundant amount of sex play with them. This auspicious beginning seems to have deteriorated subsequently, for at ages sixteen and seventeen they reported having had comparatively few female friends and companions—fewer even than the other homosexual offenders. This lack of interest in or unpopularity with females is reflected in the relatively large number who had never petted. However, those who did pet had a moderate number of partners.

The conflict of homosexuality and heterosexuality is also apparent in a study of their petting techniques. Of those who had petted, 80 per cent had never placed their mouths on female genitalia, the third largest “never” percentage recorded. This is partly because so few-only about a third—of the homosexual offenders vs. minors married. Nevertheless, only a small number of the married males had cunnilingus with their wives (20 per cent) or with extramarital and postmarital partners (7 per cent). In terms of cunnilingus with premarital partners, the homosexual offenders vs. minors have a middle status (15 per cent), as do the other homosexual offenders.

However, with reference to fellation the homosexual offenders vs. minors occupy middle positions in the rank-orders, half having had the experience.

Some people have considered heterosexual mouth-genital contact a form of behavior indicative of homosexuality, but it is clear that this belief is erroneous.

*186\161\2*

The age of the first coital partners (excluding prostitutes) of the incest offenders vs. minors gives no forewarning of their subsequent offense behavior, the percentages for partners aged twelve to thirteen and fourteen to fifteen being in the middle rank-order positions. However, one phenomenon that is probably the result of sample vagary does merit notice. The incest offenders vs. minors rate second, with 35 per cent, in the number of those whose first coital companions were sixteen and seventeen; yet in the following age-category, partners aged eighteen to twenty, they occupy next to the lowest position in rank-order (6 per cent); in the subsequent age-category, 21+, the percentage “bounces back” to 25 per cent. This eccentricity in the 18-20 category cannot be explained.

When asked how old they preferred their coital partners to be not one of the incest offenders vs. minors (or incest offenders vs. adults, either) gave an age lower than sixteen. While this omission may to some extent represent deception, it may also simply be because we asked for their current age preference and, as we have noted, our sample of incest offenders vs. minors is our second oldest sample, the oldest being the incest offenders vs. adults. Large proportions of both groups expressed a preference for women of twenty-five or older. One must also recall that we asked for age preference, not an age range of acceptability; a male may prefer a woman of thirty but be willing to accept for coitus a girl of fifteen. A moderate number, 11 per cent, of the incest offenders vs. minors said they preferred girls of sixteen or seventeen.

Aside from their offenses with their daughters or stepdaughters, the incest offenders vs. minors display no salient features in other forms of incest, though they do exceed the prison- and control-group individuals in incest with sisters and sisters-in-law.

*144\161\2*

The aggressors vs. minors were raised under quite adverse circumstances: interparental friction, poor relationship with both the father and mother, and a quite unstable home life which often resulted in the boys’ being sent to institutions. With this background many of them became juvenile delinquents.

The aggressors vs. minors may be characterized as irresponsible, aggressive, and amoral young men seeking the gratifications of today with little concern for the future. They were quite active sexually, beginning at an early age, and seem to have sought variation and novelty in both techniques and partners, which led them into a considerable amount of sexual experience with other males and with animals.

Their drive, impulsiveness, and inability to defer gratification seem also to have produced hasty and brief marriages, many of which soon became unhappy.

One can see that individuals with this kind of personality or life philosophy would repeatedly run afoul of the rules of society. However, some of them were not simply thoughtless, hot-blooded young men but were plainly antisocial and criminal. In consequence the aggressors vs. minors have an unenviable record of serious offenses, violence, and recidivism. Separating the dangerous and criminal men from what one might call the overactive extrovert troublemakers is a difficult task, but one that therapists and parole boards must attempt.

*102\161\2*

Heterosexual offenders vs. adults are adult males convicted of sexual contact, without the use of force or threat, with females aged sixteen and older who were not related to them. We have chosen the sixteenth birthday as the beginning of adult life for a number of reasons:

The average sixteen-year-old is biologically adult. She has attained the basic physique which will be hers the rest of her life even though it may be altered by additional adipose tissue and ultimately by the deteriorations of age. She is sexually mature, being capable of conceiving and bearing children; she is physically as capable of sexual response as she ever will be, though this capacity may be masked by inexperience and inhibition. Her strength and motor coordination are sufficient to meet the needs of adult life. She has developed the secondary sexual characteristics that all peoples regard as the distinguishing features of adult females. Throughout human history the majority of the societies of the world have regarded the sixteen-year-old as physically eligible for an adult sexual life.

From a social point of view the average sixteen-year-old has at least a basic knowledge of the behavior that society expects from adults, and sufficient motivation and control to conform to this expectation. Her IQ will not be significantly altered with passing years—her judgment may improve and her fund of knowledge increase, but she has fully developed her fundamental intellectual equipment. In brief, if she is mentally dull at sixteen, she will be no brighter at twenty-one or fifty-one. Until this century, when we artificially protracted childhood, the sixteen-year-old female was considered sufficiently mature, intellectually and emotionally, to function as an adult member of society. In our forefathers’ day, to which we are inclined to look back with respect and pride, sixteen was not considered an unduly early age at which to marry. In some, usually rural, areas today, the number of sixteen-year-old brides is not inconsiderable. We forget that in treating teenagers

as children we encourage them to behave as children, while actually they are capable of adequate adult behavior.

There is great danger in assuming, as we do, that maturity can be accurately calibrated in years. If we insist that sociosexual activity be permitted only to the emotionally and intellectually mature, we should logically withhold permission from vast numbers of individuals aged beyond the magic numeral twenty-one. In our culture whether a given type of sexual behavior is permissible or not depends largely upon the age of the participants: virginity in a teenager is laudable whereas in a forty-year-old it is pathological. If John, aged twenty-one, has an affair with the thirty-year-old divorcee who works in Joe’s Bar, society remains indifferent. If a few people are outraged, they will find that authorities turn a deaf ear to their complaints. But if John has an affair with a sixteen- or seventeen-year-old, the picture is quite different; now society does not look upon him as merely a sower of wild oats or a lucky man (depending upon one’s point of view). John is now a corrupter of youth, an affront to morality, and a statutory rapist. At the base of this attitude is the feeling that John has taken unfair advantage of someone who is not intellectually and emotionally mature. Tin’s feeling is unaltered by the knowledge that the divorcee has an IQ of 80 and a sense of social responsibility worthy of a ten-year-old, whereas the younger girl is an A student in high school and noted for her maturity—the fact that she shows such promise makes John’s offense even more reprehensible.

Going into the matter more deeply, one finds that the situation hinges upon some hard facts. Society has had 30 years in which to make the divorcee conform to its norms of sexual morality and has failed. Legal pressures could be invoked only with some difficulty and effort, and no one is sufficiently concerned to exert them. The divorcee’s parents and relatives, and society in general, have given up. In the case of the younger girl, however, society still has the opportunity of modeling her according to its desires. There are parents and relatives who do not realize that she is no longer a child and who feel an obligation and desire to govern her behavior; they are intimately concerned with her life; they have not relinquished her to her own individuality. There are comprehensive and elastic statutes that can be easily brought into play; proof of coitus is not necessary—almost any circumstantial evidence can be construed as contributing to the delinquency of a minor. The girl’s participation, her intellectual and emotional status—these are of small consequence. Society’s age-grading hierarchy has been affronted and someone must be served up as a propitiatory sacrifice.

The above lengthy and extreme example is illustrative of the inane but inescapable problems we make for ourselves in our necessary attempts to regulate behavior.

3. Other professional scholars have also used age sixteen as the critical dividing point, and note also that this is the demarcation age in compulsory school attendance, and is also recognized as a turning point in child labor laws.

What makes the heterosexual adult offenses a singularly difficult problem is the fact that among all types of sex offenses society is caught in a contradiction. One can easily see the need for preventing forced sexual acts; one can readily agree that sexual acts constituting a public nuisance should be repressed; one can see that parents have the right to protect their children from relationships they deem undesirable; one can, with more effort, find some justification of the position that in a democracy the desires of the majority should prevail when it comes to the permissibility of homosexual behavior. But it is difficult to find logic in our culture vis-a-vis adult heterosexuality. On one hand we stress and encourage the development of heterosexual behavior— the literature, the advertisements, the movies, everything relentlessly dins in the order: be sexually attractive, find romance, get a mate! On the other hand we strive to prevent heterosexual coitus, the logical end-product of the social campaign for heterosexuality, in any situation other than legal marriage. We tread on the accelerator and brake simultaneously; this may result in the desired speed, but it is rough on the mechanism. If early marriage were feasible for everyone, our position would be more tenable, but our complex civilization demands that marriage be delayed. Furthermore, we have never squarely faced the fact that some individuals do not wish to marry and that some others should never marry. Society makes no provision for them, but neither does it exempt them from its prosexual crusade.

Cases of substantial physical force or duress have been eliminated from this category of offenders vs. adults, but the word “substantial” demands discussion. We have eliminated cases where force or duress exceeded the boundaries of what is socially tolerable. Our society expects the male to be the aggressor in heterosexual relationships, and a certain amount of physical force and duress is consequently acceptable and perhaps even socially necessary. Girls are frequently subjected to rather intense and effective duress which takes many forms: threats not to date them again, threats to impair their popularity through adverse comments, even threats to make them walk home—all these are not only common but are accepted as a part of social living. The same is true with physical force, but here a delicacy of judgment is necessary. A man may, for example, grasp a female (known to him, and otherwise socially suitable as a sexual object) by the shoulders and pull her toward him. He must judge by the degree of resistance whether to continue pulling and how much energy to exert. In brief, he is expected to overcome maidenly modesty or even mild disinclination, but not to overpower an active aversion.

Our method of retaining or eliminating cases may best be illustrated by a few simple examples. Concerning duress we would retain an ‘I’ll-make-you-walk-home” case, but exclude the male who threatened ‘I’ll slap you silly.” Concerning force, we would retain the case where a male touched, or briefly held, or pulled an unwilling female, but we would exclude cases where she was struck or physically overpowered.

In the preceding pages we have referred so often to age sixteen that the reader should recall that the offense category under consideration involves females aged sixteen and older. Some of these women were in their twenties, thirties, and forties; at the time of the offense some had never married, others were currently married, and still others were widows or divorcees.

Penalizing a male for a mutually voluntary act with a teen-age female seems rational to some people, but with older women the rationale tends to evaporate. Male virginity is, as we said before, often thought a virtue in early life; with the passage of years it becomes successively an embarrassment, a social detriment, and finally ipso facto evidence of psychological maladjustment. Barring exceptional circumstances such as priesthood, the public would agree with the psychiatrists and psychologists in saying that there was something seriously wrong with a man of forty who was still a virgin. Thanks to our double standard of sexual morality, we do not so harshly judge females, but even so the middle-aged virgin is not regarded as a complete woman and is suspected of emotional maladjustment. The stereotype of the embittered prudish spinster seems to be offered as the reward to the woman who does not marry and who does obey society’s stated wishes concerning premarital coitus. In the lower socioeconomic level protracted virginity is often considered ridiculous and a negation of human nature. This attitude is coarsely but succinctly summed up in the gibe often directed at virgins, “What are you saving it for, the worms?” To most persons in this social milieu it is incomprehensible that a man should be punished for a sexual relationship with a mature unmarried female.

The family is the foundation of human society and the husband and wife are the basis of the family. Sexual gratification is indisputably one of the prime motivations for marriage, especially for the male, and later serves as a bond to maintain the marriage. Society has a vested interest, therefore, in fostering heterosexual desires, restricting them so as to encourage marriage, and insuring the durability of the marriage by discouraging sexual gratification with anyone other than the legal spouse. This latter point would seem to prove the necessity for laws against extramarital coitus. However, such laws conflict with some inescapable and unfortunate facts: couples are often mismated in their sexual needs; people become old, ugly, and sexually unattractive; years of sexual intimacy frequently make one’s mate less and less sexually attractive, and a growing desire for at least occasional novelty manifests itself. Although we resist the idea, man, like his primate relatives, is not a wholly monogamous mammal.

Because of these facts our laws and attitudes concerning adultery sometimes destroy rather than preserve marriages: the dissatisfied spouse ends the marriage, whereas if it were socially permissible to find sexual gratification outside the marriage, the spouse would in many instances wish to maintain the marriage. In southern European and Latin American nations there are many stable and socially effective families in which the husband (and occasionally with consent of the wife) obtains most of his sexual satisfactions elsewhere. This is, of course, done discreetly and with suitable regard for the feelings of his wife who, in turn, is careful not to pry. This sort of arrangement is no complete solution to the problem of society’s need for a stable family versus the individual’s need for a more varied sex life: some degree of jealousy and friction is almost inevitable. Aside from jealousy, even the most liberal, sophisticated wife would be vexed to find that she could not buy the new coat she so much desires because her husband has just paid the rent for his mistress’s apartment. The broad-minded husband, gratified by his wife’s happiness in an extramarital lark, still bitterly resents the innuendoes of his associates.

Lastly, it is axiomatic that while emotional involvement leads to sexual activity, such activity also leads to emotional involvement, and deep emotional involvements with a person other than one’s spouse are a distinct hazard to the continuation of marriage. The “emancipated” person who feels that an occasional extramarital adventure adds spice to life and keeps the marriage from lapsing into sexual tedium is sometimes surprised to find that his or her emotions have gotten out of control to the detriment of the marriage.

Within our present culture the problem is insoluble, and as a byproduct of its insolubility a substantial number of men and a few women are being supported in penal institutions at the expense of all of us who have failed to devise some workable solution.

*60\161\2*

The average (median) individuals of the various groups ranged in age from twenty-six to fifty at the time they were interviewed (see Table 2). The relative antiquity of the two oldest groups, the incest offenders vs. minor and adult daughters, is prerequisite to their offense. These two apart, there is no serious “built-in” selectivity favoring age or youth in any of the other groups, and the age variations can be studied as elements associated with the offense behavior.

The youthfulness of the prison group, whose average member was twenty-seven, is in keeping with that in most penal institutions. This is our third youngest group.

The average control-group male was thirty-four when he contributed his case history. This places him in the middle of a rank-order of age: about half of the other individuals in this study were older than he, and half were younger. This age is also about the halfway point in life, (lie average age of death for U. S. males now being in the late sixties.

Since our interviewing has spread over two decades, a simple table of the ages of the men at the time of reporting is insufficiently descriptive. Consequently we have tabulated our sample according to decade of birth. A glance at Table 3 shows that we have essentially no one in our study who was born after the beginning of World War II; those who hope for enlightenment concerning current juvenile behavior are doomed to disappointment. Rather few in our sample were born in the decade 1930-1939. In only our younger groups—e.g., the aggressors vs. minors, the peepers, and the aggressors vs. adults—were one fifth or more of the members born in that decade.

The bulk of the sample derives from the three decades following the turn of the century: 1920-1929 accounts for roughly one third of the sex offenders and control group and two fifths of the prison group; 1910-1919 accounts for roughly one fifth to one quarter; and 1900-1909 was the birth decade for from 7 to 36 per cent of our control group and sex offenders. In the decades prior to 1900 one finds nearly one fifth of the control group, but fewer sex offenders (14 per cent) and still fewer of the prison group (11 per cent).

*17\161\2*