Most doctors and nurses have received little training about sexual matters during the course of their undergraduate years, and indeed it can be argued that such a training is better provided at the postgraduate stage when they are not so preoccupied with the exploration of their own sexuality. Chapter 13 gives an account of the different ways of studying the consultation process. One of the models oudined can be used to provide a framework within which the interaction between the patient and the doctor or nurse, can be examined at the time the events are taking place. The importance of developing doctors who can think about these happenings has been stressed by Norell, who says that the consultation should be considered as an organic entity (Norell, 1984). Marinker suggests that not all consultations are problem solving, but that some are more like ‘a piece of theatre, a celebration or an expiation’; not to be valued as crosswords but more as poems (Marinker, 1986). The intuitive side of the consultation, suggested in the quotation from Chesterton above, has been explored by Neighbour.

Such an approach can become vague and sentimental if it is not balanced by a rigorous use of the intellect.

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A review of the literature on sterilization is interesting on four counts.

1. It is noticeable that the total number of papers on this subject is small compared with the numbers relating to other methods of contraception. This is a surprising finding considering what

a profound difference these procedures make to the lives of so many citizens.

2. Nearly all the papers on sterilization discuss possible risks of physical sequelae, looking, for example, for disease of the genital organs following vasectomy.

3. There are few studies on changes in sexual behaviour after sterilization, and very few on emotional sequelae.

4. Advice on counselling before either female sterilization or vasectomy is minimal, although there is a general consensus that it should be undertaken.

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A myth exists, even among staff, that it is impossible to have intercourse with a catheter in situ and this needs to be diffused. If the person wishes to use this myth as an excuse for not having intercourse then that is another problem, but a catheter does not need to be a bar. Women need informing that the catheter is not in the vagina but in the urethra, and body fantasies must be explored. Again, there may be a need for addressing practicalities like position and whether the catheter can be spigotted, or whether continuous drainage should not be interrupted, in which case it is important that neither partner lies on the tubing. For men, advice on folding back the catheter, if necessary taping it, and using a condom over it may be needed. In any event, these areas of anxiety need addressing as there is great potential for emotional and practical difficulties (Mooney, Cole and Chilgren, 1975).

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Homosexual offenses. In a sizable proportion of the homosexual offenses there was no actual physical contact between the offender and the object of his offense, as was explained earlier. These were usually cases in which sexual overtures were made, but further action was blocked by the recipient or by an onlooker, who in most cases was actually a police officer out of uniform.

These noncontact offenses have been combined with the contact offenses, in contrast to our practice of separating such categories of heterosexual offenses, for two reasons: first, there is every likelihood that the men would have gone on to a contact offense if they had not been interrupted. This is not so true of the heterosexual noncontact offenses. Secondly, all homosexual solicitation is an offense in itself, whereas this is not true of a heterosexual approach, although it sometimes results in arrest. The noncontact homosexual approaches totaled over a fifth of the offenses involving two adult males, dropped to 11 per cent in the offenses against minors, and represented only 3 per cent in the cases where the homosexual approach was to a boy under eleven.

While over a fourth of the homosexual offenses with minors and adults consisted of nongenital or manual-genital petting, the remainder progressed to oral or anal contacts. In contrast, in the offenses with children, this kind of petting constituted well over half of the offenses. The difference is accounted for under the subheading of manual-genital petting, since nongenital petting shows virtually no variation among the three age groups. When minor and adult males are the partners, fellation (mouth-genital contact) is apparently most likely to occur. Anal intercourse, considered by many as a sine qua non in homosexual offenses, appears to play a comparatively minor role, ranging from 6 to 14 per cent. It is possible, of course, that it occurred in some additional offenses but was not included in the specific charges which were filed.

In comparing these homosexual offenses to the heterosexual groups discussed earlier, one can note a number of similarities in the sexual techniques used. They would include such behavior as nongenital and genital petting and mouth-genital contacts. In fact, one heterosexual group, that of incest offenses vs. children eleven or under, actually exceeded the parallel homosexual group in the degree to which mouth-genital behavior occurred.

In summary it can be said that:

Sexual offenses that can bring conviction show a wide range of behavior ranging from no physical contact to oral and anal techniques and rape.

Coitus or attempted coitus is the usual offense against minor and adult females. The incidence here is two thirds or more in the non-aggression, aggression, and incest classifications.

The use of force is positively related to the completion of coitus in the offenses against children and negatively related in the offenses against minor and adult females.

General petting behavior, and more particularly genital touching and genital-oral contacts, predominate in offenses involving children, especially in the nonforce and incest types of offenses.

Preferred sexual techniques in homosexual offenses vary according to the age of the sexual partner; manual-genital petting predominates in the offenses with the youngest boys, and mouth-genital contacts with the two older groups.

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In this chapter the criminality (as defined by arrest and conviction) of the various sex-offender groups will be compared with the criminal histories of the prison group. All the sex-offender groups have members who have committed nonsexual offenses. It is possible to examine the available criminal records of the sex offenders and the prison group as they relate to juvenile criminality, both sexual and nonsexual; recidivism; the ages at the occurrence of convictions of varying severity; the proportion of various types of nonsex offenses committed by each group; the per capita offense experience; and the relative proportions of sexual versus nonsexual offenses.

The criminal behavior of the prison group will serve here as a bench mark.

The prison group has a diversity of criminal experience. Out of this diversity arises a pattern which has been the subject of study of the social scientist—some ideal person who may be called the “normal” delinquent. While much of his career in crime is still terra incognita, some of the more obvious landmarks of his experience may be charted.

The criminal career of the normal delinquent starts early in his life, usually on the streets of an urban community. A certain amount of his early behavior has a play element in it, often of a malicious or destructive character. In his childhood the group of friends on the street corner become his source of rewards and punishment. Respect,, love, and status all arise from the social life of the gang. Part of the style of life of the group of boys involves criminal activity, whether fighting, vandalism, theft, or drug use. Involvement with the police and the courts and finally correctional institutions becomes part of their life experience. Conventional society—that is, the part of society which thinks of itself as noncriminal—becomes an object of derision and depredation.

A few of these males get into professional crime, either of an individual tradesman variety or of the syndicated business variety. The broad majority become thieves of a less competent kind, alternating their times of freedom with periods of imprisonment.

In crude outline this is the expected life style of the normal criminal who fills the police lockups, the court dockets, and the prison cells. Early criminal involvement, usually in a gang context, crimes of a property nature, intermittent imprisonment, and attitudes at variance with those of the middle classes are part and parcel of his career.

The members of any sex-offense group follow the pattern of the nonsexual criminal to the degree that the origins of their behavior are not special, but common to a general pattern of antisocial behavior.

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We have considered as a marriage any common-law marriage (one in which a man and woman live openly together as husband and wife although no legal marriage ceremony has occurred) that lasted continuously for at least one year. The number of common-law marriages that do last this long or longer may surprise the readers who belong to the upper and upper-middle classes where such marriages are rare. The control group made the fewest common-law marriages—only 4 per cent. Next are 11 groups with percentages of from 8 to 17 inclusive. The remaining four groups have large proportions of common-law marriages: the peepers (22 per cent), the homosexual offenders vs. adults (23 per cent despite their higher socioeconomic status), the homosexual offenders vs. minors (24 per cent), and the aggressors vs. children (32 per cent). The large figure for the aggressors vs. children fits in with their general alcoholic, disorganized, and shiftless style of life. The two homosexual-offender groups and the peepers, however, pose a problem. Since all three had unusual difficulty in adjusting to a heterosexual life, perhaps their common-law marriages represent a hesitant experimental approach and qualified commitment to the legal sexual relationship society expects and demands.

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Among those with heterosexual play, no group had more than 15 per cent of its members experienced in mouth-genital contact prior to puberty. The control group had the fewest (4 per cent), and the homosexual offenders the next fewest. At the other end of the scale, two of the three heterosexual-aggressor groups occupy first and third ranks (15 and 12 per cent)—a possible indication of their demonstrated interest in heterosexuality and of an inclination to exploit all possibilities. The aggressors show the same interest in coitus, ranking second, fourth, and fifth with percentages ranging from 69 to 73.4 In brief, when a future aggressor had heterosexual play he pursued it to the physical ultimate in from two thirds to three quarters of the cases. The heterosexual offenders vs. adults, typified in later life by their success in obtaining coitus, rank first (78 per cent) in prepubertal coitus, and the heterosexual offenders vs. minors lag not far behind. At the bottom of the rank-order are two of the three homosexual-offender groups and the control group, the latter again occupying the last rank (38 per cent).

With regard to techniques among those with homosexual play, masturbation is not so common as to prevent comparisons (see Table 25). It was most used by the homosexual offenders (78—90 per cent), followed fairly closely by the peepers.5 A number of our numerically smaller groups were unavailable for comparison, since too few of them had engaged in homosexual practices. From 7 to 42 per cent of various groups had had mouth-genital contact. The homosexual offenders vs. adults, the most homosexually oriented of all, had the 42 per cent—a figure far greater than the peepers, who ranked second with 30 per cent. The other two homosexual-offender groups are in the upper half of the rank-order, the homosexual offenders vs. minors ranking third and the homosexual offenders vs. children sixth. The heterosexual offenders, the prison group, and the control group all rank in the lower part of the scale, below the 20 per cent level. Interestingly, the prison and control groups are rather alike as far as homosexual techniques are concerned, whereas they were dissimilar in their heterosexual techniques. In 12 of our comparative groups, the proportions of those with homosexual mouth-genital contact exceed by a ratio of two-to-one or more the proportion with heterosexual mouth-genital contact. In the remaining four groups the proportions are essentially equal.

Of those with prepubertal homosexual experience, some 37 to 38 per cent of all three homosexual-offender groups had had anal coitus. The next highest group (with 29 per cent) is the heterosexual aggressors vs. adults.0 This high position may be significant, since the calculations for’ the numerically small groups of aggressors vs. minors and children suggest that an equally great or greater percentage of their members had also experienced anal coitus. Indeed among the aggressors vs. children and minors the percentage reporting anal coitus exceeds the percentage reporting mouth-genital contact.

In the rank-order of anal coitus the control and prison groups are more or less central, while the lower ranks are occupied by the heterosexual offenders vs. adults and minors who were so successful in obtaining coitus as adults. Relatively few of them had homosexual experience as children, and of these few only a small percentage used oral or anal techniques.

Even in prepubertal homosexual play the persons ultimately convicted of forced heterosexual relations show a higher percentage of individuals who had only active anal coitus than any other group. Moreover, two thirds of those convicted of aggressive heterosexual acts had a combination of active and passive anal coitus, the second largest percentage recorded. The most homosexual of the three homosexual-offender groups (those convicted of contacts with males sixteen years and older) show only 6 per cent who had solely active prepubertal anal intercourse, whereas 31 per cent reported passive anal coitus and 62 per cent reported both. On the basis of our limited data (unfortunately in over a third of the cases it is not known whether the anal coitus was active, passive, or both) it appears that active anal coitus before puberty is positively correlated with subsequent aggressive heterosexual acts. Interestingly enough, none of the control group reported active prepubertal anal intercourse, whereas 22 per cent of the prison group with anal coitus before puberty reported it was active rather than passive Some interesting differences in the degree to which various techniques were employed may be seen when prepubertal heterosexuality and homosexuality are compared. Manual stimulation of genitalia was commoner to the heterosexual, being used by from 72 to 100 per cent of those who took part in heterosexual play, whereas in the homosexual sphere this technique was employed by from 43 to 90 per cent. Mouth-genital stimulation was experienced by from 7 to 42 per cent in a homosexual situation, but by only 4 to 15 per cent in a heterosexual setting. Anal coitus was a substantial homosexual phenomenon (10 to 38 per cent), but extremely rare in the heterosexual. Vaginal coitus, for which there is no homosexual analogue, was experienced by from 38 to 78 per cent of the members of the various groups.

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Their involvement with the law as adults was rapid. By age sixteen nearly one fifth (third in rank-order) had been convicted; subsequently they attain second rank with 46 per cent convicted by age eighteen: 62 per cent by twenty and 79 per cent by twenty-three. By age thirty they are second in the rank-order with 93 per cent of them having been convicted of some offense. On the other hand, their offenses as measured by the proportion of men sentenced to a year or more do not seem to have been particularly grievous, and many of them were nothing more than peeping.

The average (median) peeper was first convicted at 19.5 years of age, tying with the prison group for second in youthfulness at first conviction. In terms of their average age when first convicted for a sex offense the peepers are the youngest by nearly a full year, being 22.5 years old.

Three fifths of their convictions were for sex offenses—owing rather largely to numerous peeping convictions. A moderate proportion of the men (45 per cent) had been convicted solely for sex offenses.

The peepers had the third largest per capita number of convictions, 4.24, and in number of misdemeanors resulting in imprisonment (2.18) they were second only to the exhibitionists. They were again second in number of sex-offense convictions per capita: 2.52, of which 1.61 were for peeping. Their felony convictions were moderate. All in all, we may view the peepers as not given to serious antisocial behavior but very prone to minor criminality.

Their nonsex offenses were not noteworthy except that there was a slight emphasis on crimes vs. property. These account for 42 per cent (third in rank-order) of the peepers’ nonsex offenses, and they were chiefly theft—a crime readily associated with peeping.

Their sex offenses, aside from peeping, were most commonly exhibition (43 per cent) and offenses against willing or acquiescent females (29 per cent). Sex offenses involving force and duress account for about 20 per cent, and one must realize that a minority of peepers are capable of rape. Perhaps a more accurate statement would be that a number of rapists do some preliminary surveillance and are consequently regarded as peepers if apprehended in this activity.

In terms of recidivism there appear to be two varieties of peepers. At one extreme are those who seem to be incidental peepers: the men who peep rarely and only when opportunity strongly beckons; presumably they constitute the one quarter of the peepers with only one conviction. At the other extreme are the repetitive and often compulsive peepers, and it is they who account for the fact that 30 per cent of the peepers had four to six convictions and another 20 per cent had seven or more. These are relatively large figures, especially the latter, which is the second largest recorded. Note that only 9 per cent of the prison group had seven or more convictions.

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The risk of acquiring HIV from a fluid that was splashed onto broken skin has been estimated to be 3 in 1000. The risk of an exposure through a splash onto a mucous membrane is estimated to be less: under 1 in 1000. As mentioned in the section on transmission, the most potentially infectious body fluids are blood, semen, vaginal fluids, and breast milk. Fluids from which there is a doubtful risk of transmission are saliva, urine, feces, sweat, tears, and vomit, unless any of these fluids is also mixed with blood. Any other body fluids, such as fluid from the lung or amniotic fluid, could potentially transmit HIV. Fluids from a person known to be HIV-positive are more infectious if they are from one whose virus is very active, as evidenced by a high viral load assay or a low CD4 count.

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