The process of thinking during a consultation, and subsequently describing what happened to a group of colleagues, soon leads to an awareness of many unspoken communications from the patient. Mode of dress, the presence or absence of eye contact, feelings of anger, despair or withdrawal coming from the patient are reported by the doctor. But, more importantly, the doctor begins to be able to study the feelings that are present in himself or herself, and to see that they may have been aroused by the particular patient in the consulting room. Thus it is the interaction, the atmosphere, the flow of feeling and action between the two people that is the subject of study and that can reveal unconscious truths about the patient. One doctor in training said, ‘I am learning to use another part of myself to help my patients.’

*360/197/1*

Sometimes referral represents a flight from the complaints presented by the patient; at other times it may be a necessity because of over-involvement with the patient’s difficulties or emotions.

*321/197/1*

A woman in her 30s, with three children from a previous marriage, came to a gynaecological clinic with her new husband. They were excited by their recent marriage and anxious for a child. She had been sterilized several years before when she had three children under the age of three years. Her marriage was under strain even then, but she had felt it could recover if she had no further pregnancies and could give more energy to her relationship with her husband.

Her sterilization was reversed but she failed to conceive, and although the new relationship was stable and supportive, she became increasingly frustrated. Furthermore, the children of her first marriage felt they were no longer valued by either parent and responded badly. Soon, she was struggling to cope with disturbed adolescents exhibiting antisocial behaviour, as well as her own anger and her husband’s disappointment. She bitterly regretted her operation and felt she should have dealt with the difficulties she had experienced with contraception in her first marriage before requesting sterilization.

*245/197/1*

The use of contraception to help with other problems such as the control of heavy periods, premenstrual tension and hormonally related epileptiform fitting can be considered. The most emotive of all contraceptive methods is sterilization, its importance lying in its permanent nature. Personal choice for the patient is thus even more important. Major issues are raised when a person is unable to exercise their choice because their disability renders them incapable of giving informed consent. Doctors need to consider their own feelings and not allow them to interfere with the decision making. It is not uncommon for the doctor to be pressurized by interested parties for or against the decision to sterilize. Where informed choice is not possible, the ethical and legal implications will need a judicial opinion if the patient is legally an adult, as no-one else is in a position to give consent on her behalf.

*207/197/1*

Certain types of sex offenses are by their very nature more likely to be reported to the authorities than others. Offenses involving aggression clearly fall in this vulnerable category. Similarly, but for different reasons, there are special risks associated with acts of pedophilia. Younger children have little sense of guilt and are poor secret-keepers. Thus any male sexually accosting a child, male or female, is running a strong risk that the event will be described to others and eventually reach the ears of a concerned adult who will lodge a complaint. Yet there are pedophiles who have been known to operate for long periods of time, who made dozens of sex contacts with young children, and who have never been reported to or apprehended by the authorities. The careful choice of the social milieu in which to operate, the avoidance of force, and the skill and judgment of the pedophile in selecting a compliant child probably are important factors in such cases. Although the general circumstances surrounding pedophilic offenses are carefully chosen, the inevitably vulnerable link in the chain of events-secrecy on the part of the child—is largely an unpredictable element in the picture. The high degree to which the arrest of the offender in offenses involving children and minors was dependent on whether or not the object kept silent is shown in Figure 27.

In the four major offense categories involving children and minors the factor of dependence on the secrecy of the young person was most strongly shown in the offenses vs. children. The percentages ranged from 78 per cent up to 100 and were all higher by approximately ten or more percentage points than in the comparable offenses vs. minors. In the great majority of these categories there were no means by which the offense could have become known unless the child or minor reported the event to someone. What usually happened was that the youngster described it to a sibling or more often a schoolmate, who in turn divulged it to an adult, who then made the official complaint. As will be shown later, few minors and still fewer children made direct reports to the authorities. The fact that the offenses vs. children reflect a higher degree of exclusive dependence on the secrecy of the child indicates that the circumstances probably were more carefully chosen. The element of privacy was of paramount importance. The extreme is seen in the cases of incest vs. children, in which the risk of detection or observation by outside sources was reduced to practically nil.

In offenses vs. adults certain other factors enter into an evaluation of the risk taken by the offender: the likelihood that the case will be reported to the authorities and the chances that the person who committed the offense can be located and identified. Such elements as the time of the day, the conspicuousness of the action, the presence or absence of witnesses, the degree of offensiveness of the act, whether the offender was known to the person who was approached, as well as whether he was on probation or parole and hence already known to the police—all these can be taken into consideration.

One purpose in making these estimates of the degree of precaution shown at the time of the offense is to examine the evidence for the “flight into custody” motif often advanced in the psychiatric, and more often psychoanalytic, interpretations of the relationship of crime and guilt. This theory suggests that the lawbreaker’s sense of guilt often leads him to behave in such a way that his arrest and conviction are almost inevitable. Presumably by creating an opportunity to expiate his offense he gains relief from the pressures of his intolerably heavy guilt. This mechanism is supposed to take place largely at an unconscious level. Sex offenses with their strongly moral overtones appear to present a particularly appropriate framework for examining this theory of foolhardy risks. If the hypothesis is sound, one might well assume that the types of sex offenses that are under the most disapprobation socially would tend to produce in the offender the strongest sense of guilt and hence best illustrate the phenomenon. When we examine the data, however, this does not particularly seem to be so. According to the table, aggression offenses vs. adults and exhibition show the greatest degree of high risk-taking, while a moderate risk with possible apprehension was strongly evidenced in peeping, and moderately in incest and homosexual offenses vs. adults. Most unlikely to be apprehended were the offenders involved in the heterosexual offenses vs. adult women. Incest and homosexual offenses show about a quarter of the cases as unlikely to be detected. While the theory of “flight into custody” might apply in individual cases, it does not seem that the data here bear it out in general. Peeping, a minor offense, is high in risk-taking, as is exhibition. Incest with daughters sixteen and over, andhomosexual offenses with adult males are both highly taboo but do not reveal comparatively high levels of foolhardy risks. There is, of course, the possibility that the present materials are not complete enough for this type of analysis, since all the current offenses were in fact detected.

Alternative explanations of high risk-taking cannot be overlooked, such as an inability to judge the risks because of low intelligence, projection by the male of his own feelings of sexual arousal to the female, unforeseen unlucky “breaks,” and lack of judgment resulting from a narrowing of perceptions because of emotional stress. The last point would be particularly applicable in sex offenses.

*383\161\2*

Two of the tripartite groups, the heterosexual offenders and the incest offenders, had fewer per capita convictions than the prison group; one tripartite group, the aggressors, had all of its constituent groups with more convictions than the prison group; and the remaining tripartite group, the homosexual offenders, was mixed in this respect. Both the peepers and exhibitionists had more convictions per person than did the prison group; this reflects their tendency toward compulsive repetitive peeping and exhibition rather than toward other criminality.

The offenders and aggressors against children of either sex tend definitely to have more convictions than those who offended or aggressed against minors and adults.

Differentiating the offenses according to whether they were misdemeanors or felonies is not particularly profitable even when one deals, as we have, with only misdemeanor and felony convictions resulting in imprisonment. The men whose sex offenses are often judged as more nuisance than danger, for example, peepers and exhibitionists, have large per capita numbers (2.18 and 2.47 respectively) of misdemeanors. Similarly those whose sex offenses do not outrage society— i.e., the offenders vs. minors and adults—have, like the prison group, more misdemeanors than felonies. On the other hand, those who deeply offend society, those who use force or become involved with children, have more per capita felony convictions than misdemeanors. Furthermore, within every tripartite group the offender or aggressor against children has the largest number of felony convictions.

The criminality of the aggressors is again clear in a simple tabulation of the percentages of individuals with various numbers of convictions: they had from 14 to 28 per cent of their members with seven or more convictions whereas only 9 per cent of the prison group equaled this unenviable record. This same table also illustrates the tendency for offenders or aggressors vs. children to have had more convictions than offenders or aggressors vs. minors or adults.

Confining our attention to convictions for sex offenses, we find that the exhibitionists, as the tables show, have the dubious honor of having had the largest number of convictions: 3.12 per person. The peepers had the next largest number (2.52), and the incest offenders vs. adults the fewest (1.24). In three of the four tripartite groups the offenders or aggressors against children have more per capita sex-offense convictions than those whose sexual objects were minors and adults. In all four tripartite groups the aggressors or offenders vs. adults had the smallest per capita figure. While it is possible, but not probable, that those whose sexual acts concerned adults “learned their lesson” from punishment more readily than those who were involved with younger people, we feel the per capita statistics simply show that it is dangerous to consort sexually with minors and even more dangerous to do so with children.

The sex offenses mentioned above were for most groups chiefly the ones for which they were named. Most sex offenders specialize, so to speak, in one type of offense which we refer to as the specific type. Thus, for example, of the 1.39 sex offenses per offender vs. adults 1.06 were offenses against adult females and 0.34 were other types of sex offenses. The offenders and aggressors vs. adults tend to confine their offenses to one type whereas the offenders and aggressors vs. children and minors are more prone to other types of sex offenses in addition to the one for which they were named. In all but two groups the per capita number of specific type sex offenses (the “label type,” so to speak) heavily outweighs the number of nonspecific type offenses. However, among the aggressors vs. children the two figures are rather close, and among the aggressors vs. minors the nonspecific sex offenses actually slightly exceed in number the specific type. These two aggressor groups, it will be recalled, also showed a lack of specificity in broader categories of crime: relatively few of them confined themselves to sex offenses.

*345\161\2*

Premarital coitus with the future wives resulted in a substantial number of pregnant brides, especially for the incest offenders. Between one fifth and slightly over one quarter of them married pregnant girls, and they occupy first, third, and fourth positions in a rank-order. There is not the high positive correlation one might expect with incidence and frequency of premarital coitus. This is because we are not counting simply impregnated females, but only those impregnated females whom the males married, and the more moral and conservative men are particularly apt to marry girls whom they have “gotten into trouble.” Furthermore, our calculation is based on pregnancy at marriage and disregards pregnancies terminated prior to marriage. Consequently, some of our heterosexually most active groups, such as the offenders vs. adults and the prison group, do not rank high whereas some of our inactive groups, such as the incest offenders vs. minors, hold top rank.

A small number of men in our sample married women who had borne them a child prior to the marriage, but too few individuals were thus involved to permit significant conclusions.

*307\161\2*

A number of men said they had experienced orgasm before reaching puberty—from 25 per cent for incest offenders vs. adults to 62 per cent for homosexual offenders vs. adults. The aggressors and incest offenders seem to include fewer members with prepubertal orgasm than other groups, and the control group likewise had few (29 per cent) such individuals. The homosexual offenders, peepers, and prison group had a fair proportion (half or more) of persons experienced in prepubertal orgasm.

There seems only a moderate correlation between the age at which the median individual of a group attained puberty and the age at which he experienced his first prepubertal orgasm. The offenders vs. minors and adults reached puberty relatively late and also had prepubertal orgasm late, at ages 10.7 years and 10.9 years respectively. Conversely the homosexual offenders vs. children and adults who reached puberty early had early first prepubertal orgasms (ages 9.4 and 9.8 years).

From half to two thirds of the initial prepubertal orgasms were induced by masturbation. Heterosexual coitus is the second most important source (2 to 40 per cent), with homosexual activity a close third (4 to 17 per cent among all groups except the homosexual offenders, 24 to 36 per cent of whose members attained their first orgasms from homosexual activity). Only among the homosexual-offender groups, the peepers, and the controls did homosexuality outweigh heterosexual coitus as a source of the first prepubertal orgasm

*269\161\2*

The peepers tend to be either the only child or the youngest child in their families, and also have very few sisters. Their relationship with their parents was good, although the parents themselves did not get along very well. The poor heterosexual life that typifies many peepers was foreshadowed in childhood when two fifths of them lacked female friends.

In adult life relatively few peepers petted and those who did so began late. This is in keeping with the fact that in their midteens they also had few female friends. Premarital coitus was belated but other wise not unusual. A rather small proportion of peepers married and few had extramarital coitus. All in all, the picture is one of a somewhat stunted heterosexuality, which may explain in part their rather strong homosexual component.

The criminal record of the peepers is fairly extensive and they were especially delinquent when juvenile. However, much of their criminal record stems from habitual peeping and some exhibition.

*230\161\2*

Three stages of symptoms can occur with LGV. In the first stage, a small red bump or ulcer occurs in the genital or anal area; it is painless, transient, and usually missed. The lesion appears a few days to a few weeks after infection; it can occur on skin outside the genital and anal areas, but it occurs more commonly on the head of the penis or on the cervix or labia. The bump usually heals without a scar.

The second stage (and the most commonly noticed symptom of LGV) consists of lymph node swelling in the groin area. This stage usually occurs within ten days to six months after infection. At this point, the bacterium also enters the bloodstream, and it can cause infection at sites distant from the site of initial infection, such as the liver, lung, and brain. Although the lymph node swelling usually occurs on one side of the groin, it can occur on both sides at the same time. The lymph nodes are usually painful; they may rupture and drain pus, and the person may experience fever.

During this stage, men and women may also experience inflammation and infection of the urethra, which is usually symptom free. Women can also have infection and inflammation of the cervix.

*340\213\8*