Summarizing provides direct feedback to the patient. If accepted, the consultation moves on. If not, the patient explains what it is that she feels the doctor has misinterpreted and then the doctor tries again.

*348/197/1*

*309/197/1*

For the doctor there are the additional difficulties of weighing up the medical risks of a pregnancy in a woman of this age. It has been shown that in the years 1976 to 1987 in the UK, the risk of death in pregnancy for a woman over 40 was 10 times that of a woman between 20 and 24 years; 5 in 10 000 against 0.5 in 10 000 according to the report on Confidential Enquiries into Maternal Deaths (1991). However, there is some evidence that this risk is decreasing in the UK, as figures for 1985 to 1987 show a rate of only 2 in 10 000 deaths of women over 40 (Drife, 1992). In the end it is the couple who must be allowed to make the choice with the help of up-to-date information from their doctor. It is a delicate balance for the doctor to share the patient’s joy while providing her with realistic facts.

*271/197/1*

Hamida Kamali had an IUCD fitted nine months ago. She had no problems with it but wished for it to be removed during Ramadan. When the period of fasting (and sexual abstinence) was over, the couple felt that they would like to return to the IUCD rather than continue with condoms. At this point the doctor was able to discuss the disadvantages of such frequent coil changes, but at the beginning this had not been possible because of their apparently implacable attitude towards their religion. In subsquent years, the couple felt that the advantage of an undisturbed coil outweighed their religious scruples.

*233/197/1*

If the doctor endeavours to continue with his or her usual technique, he or she may feel at a loss when inconsequential remarks are made, like, ‘I am going to tea with Jack today’ or ‘Look at my new shoes’. A new style has to be developed where the comment is acknowledged, but then the doctor is able to pull back to the matter in hand.

*194/197/1*

Since sex behavior is by and large a fairly clandestine matter in the American culture, it is not surprising to find that in the present data over four fifths of the offenses in every category are solitary in the sense that they are committed by a single offender.

Joint participation in the incest offenses was essentially nonexistent. Among the 173 incest offenses there were actually three cases in which the offender’s wife, because of her acquiescence in the incestuous relationship, was convicted of various charges such as contributing to the delinquency of a minor, aiding and abetting the act of rape, and perjury. These wives, however, could scarcely be classified as active copartners in the incest.

It is clear from the tabulation that certain types of offenses are less likely to be joint undertakings than others. Homosexual offenses, for example, rank consistently low in multiple participants. There were less than 3 per cent of such offenses in any of the three homosexual-offense groups, and a count shows only 12 cases out of all 603 homosexual offenses. Since from many sources it is evident that there is a greater amount of group sex activity among homosexuals than among heterosexuals, these low figures represent something of a paradox. A likely explanation is that homosexual group activities doubtless take place in a more protected environment chosen with an eye to caution, and hence are less likely to lead to discovery and conviction. Both the aggression and nonaggression offenses against children similarly show a minimum of partnership in the offense. Specifically, there were only three instances of joint participation among the total of 302 cases. Apparently pedophiles are not likely to seek the aid or encouragement of an acquaintance or a friend. Undoubtedly the strong moral strictures regarding these offenses against children make it difficult to share plans or actions of this kind with others. As was pointed out earlier, pedophilic behavior, even among sex offenders themselves, is considered on the lowest rung of the moral ladder. It is also likely that the complusive nature of some pedophilic behavior is predisposing toward its solitary nature—that is, the offender needs no outside encouragement or bolstering of his nerve to the “sticking point” to reach the necessary resolution to carry through his act. On the contrary, he may be virtually propelled through it by the compulsive nature of his drives. The older average age of the pedophile is another factor which would tend to lessen gang or group activity, as would the fact that there is less need for Jd when using force against a child than there is when force is used against an adult. Setting aside incest, homosexual, and pedophilic offenses as typically involving only one person, we can then examine the remaining four groups, the heterosexual force and nonforce offenses vs. minor and adult females. Here Table 147 shows multiple participation in from 10 to 18 per cent of the cases, with the two groups of offenses vs. minors at the higher end of the scale. This provides the first clue to the relation between copartnership and the age of those involved in the sex offense. The pattern in these cases was typically an offense committed by two males, the subject and a single accomplice, and less often involved three offenders, that is, two accomplices. What might be termed actual “gang-bang” offenses, with three or more males participating with the offender, are represented in the sample by eight cases, six of them not involving force. Since such group gang activity, especially by juveniles, arouses strong feelings on the part of the public, it is worthwhile examining these ten cases more closely even though they are actually a minute part of the total sample

*371\161\2*

The frequencies are, as one would expect, low. However, if one considers only those individuals with animal contact and calculates the frequency for them alone, the resultant figures range from about 4 to 20 times per year for the average (median) persons of the various groups. The mean frequencies are, of course, higher, ranging from once a month to nearly once a week.

Examination of these frequencies raises more questions than it answers. Frequency not only bears no relationship to rurality but none to incidence either. In fact, the control group—which had the lowest incidence of animal contact—exhibits the highest frequencies in every instance but one: it is surpassed only by the heterosexual offenders vs. adults who had the second lowest incidence. The high frequencies of the control group proved to be due to the presence of a small but unusually active minority of about ten men.

*333\161\2*

The most intimate petting technique (aside from anal contact), and also the most taboo, is mouth-genital contact. Here many of the associations we have previously noted no longer appear: a male with many sexual partners and high coital frequencies does not necessarily have liberal attitudes toward mouth-genital contact. Similarly it is not uncommon for a male to have opposite attitudes toward fellation and cunnilingus, accepting one and rejecting the other.

In the matter of mouth-genital contact it is considered more taboo for a male to put his mouth on female genitalia than to allow (or encourage or pay) a female to put her mouth on his. Consequently, among males, being fellated is usually commoner than performing cunnilingus. Of those who had ever experienced fellation by a female, the incest offenders vs. children lead with 73 per cent, followed consecutively by the heterosexual aggressors vs. children, aggressors vs. adults, and aggressors vs. minors; the aggressors standing as a unit typified by a large number with such experience. It must be added that fellation was often a part of the behavior leading to their conviction. The exhibitionists rank fifth, and, at the end of the scale, the heterosexual offenders vs. adults and minors have the smallest proportions with experience, topped by the incest offenders vs. adults, the control group, and the homosexual offenders vs. adults with 38 per cent.

It would seem, then, that the offenders who use force and heterosexual pedophiles tend to seek fellation, whereas those whose interest and/or offense concerns willing older females are less interested in it or more inhibited about it.

This generalization is strengthened by studying the data on cunnilingus. Here once more we see that the most experienced groups are the incest offenders vs. children (66 per cent), the three heterosexual-aggressor groups, and the heterosexual offenders vs. children. The least experienced in cunnilingus are the heterosexual offenders vs. minors and adults (11 per cent) and, not unexpectedly, the homosexual offenders.

One must, however, realize that where taboo behavior is concerned all manner of rationalizations and the factor of availability come into play. For example, some males avoid certain types of sexual behavior with their companions or wives, but seek it with prostitutes. Other males may be inhibited about a particular act until they find themselves in the repeated intimacy of marriage or a protracted love affair which tends to erode the inhibitions. Some males are uninhibited about having coitus, but definitely inhibited about specific sexual techniques (the offenders vs. adults are a prime example), while others (such as the incest offenders vs. adults) are inhibited about sex in general. Consequently, it behooves us to look at the situations in which mouth-genital contact occurred.

First of all, let us examine mouth-genital contact prior to marriage with companions (i.e., nonprostitutes). In a rank-order of fellation experience, the three heterosexual-aggressor groups occupy the first three places (28-34 per cent), followed by the prison group and, oddly, the homosexual offenders vs. adults. The high rank of the aggressors is in keeping with our earlier findings, the fourth ranking of the prison group may be an expression of their disregard for social regulations coupled with their unusual amount of heterosexual activity, and the fifth ranking of the homosexual offenders vs. adults may simply be the result of transferring to a heterosexual relationship a technique common in homosexual relations. The groups with the least experience of fellation are the incest offenders vs. adults and minors (8-9 per cent); also low in rank-order are the three heterosexual-offender groups and the control group.

Cunnilingus with companions prior to marriage presents a roughly comparable picture in that the heterosexual aggressors vs. minors and adults rank first and second (25—33 per cent), while the heterosexual offenders vs. minors and adults, the control group, and the incest offenders vs. adults occupy the lower ranks (4-8 per cent). Inexplicably the heterosexual aggressors vs. children are also low while high in the rank-order of fellation experience—a tendency seen in less pronounced degree among the prison group.

From this rather confusing mass of premarital data we can conclude that premarital mouth-genital contact is commonest among the heterosexual aggressors and least common among the heterosexual offenders vs. minors and adults and the incest offenders vs. adults. It does not seem to be associated with pedophilia; the offenders and aggressors vs. children usually appear in the central portions of the rank-orders.

In premarital life fellation is more predominant over cunnilingus than in later life. In only three groups were more of the members experienced in cunnilingus than in being fellated, and in only two groups were they equally experienced in both.

Mouth-genital contact with prostitutes before, during, or after marriage involves a problem at present insoluble, but we shall discuss it here since most contact with prostitutes is premarital. The difficulty is that while males rather freely admit having been fellated by prostitutes (a standard offering), they are extremely reluctant to admit having placed their mouths on prostitutes’ genitalia. Very few report it, but the prostitutes we have interviewed state that a large proportion of their clients do perform cunnilingus. Consequently, we are inclined to believe our percentages are much too small.

Confining the calculations to those who had ever paid a female for sexual activity, in a rank-order of fellation by prostitutes the upper three positions are held by the aggressors vs. minors and adults and the exhibitionists. The lowest ranks (28-32 per cent) contain, as usual, die heterosexual offenders vs. minors and adults, and also the incest offenders vs. adults.

In summary, about all that can be said regarding commercial heterosexual mouth-genital contact is that it is an activity involving many of the aggressors and relatively few of those whose willing or acquiescent sexual partners were postpubertal females.

This correlation between mouth-genital contact and heterosexual aggressors, a phenomenon fitting the psychoanalytic concept of “oral aggression,” led us to tabulate those who had bitten (usually gently) their sexual partners. Such biting is commonplace as a sexual stimulus in many mammals, and hence not unexpected among humans. We found a high association between mouth-genital activity and biting. Unfortunately, in the case of the homosexual offenders we cannot differentiate the sex of the bitten partners, and hence we shall ignore them in this discussion after stating that they seem rather prone to such oral stimulation, ranking second, fourth, and eighth. We also did not differentiate biting on the basis of marital status, but since in the bulk of our cases it occurred prior to marriage we shall discuss it here.

An “ever vs. never” tabulation of biting is not very illuminating except that, as with mouth-genital contact, few of the heterosexual offenders vs. minors and adults bite. A rank-order of frequent biting (omitting the homosexual offenders) shows the heterosexual aggressors vs. minors in first place (26 per cent), the prison group second, and the heterosexual aggressors vs. adults third (see Figure 7). Again, oral stimulation seems equated with the use of force. All three incest-offender groups and one aggressor group (vs. children) occupy the lowest four ranks (4-6 per cent). This is not surprising; the incest offenders are not sexually aggressive, hence their mediocre or poor heterosexual record and their consequent seeking of sex within the family. The heterosexual aggressors vs. children are, by and large, not so aggressive as those vs. adults; they were insufficiently enterprising to obtain older females and turned to children where less effort was sufficient to achieve their aim. The fact that the aggressors vs. minors and adults rank high in biting while the aggressors vs. children rank low may relate to our finding that the former two groups rank first and second in the number of men with sadomasochistic masturbatory fantasy, whereas the aggressors vs. children rank lowest in this respect.

A rank-order of occasional (as opposed to frequent) biting reveals that the incest offenders are now all within the first four ranks, and die heterosexual offenders occupy the lower four ranks. Virtually all groups had more members who bit occasionally than frequently; the aggressors vs. minors and the offenders vs. adults are the only exceptions. However, in some groups the occasional biters were nearly equaled by the frequent biters: the prison group and the peepers.

In all three measurements, ever-never, occasional, and frequent biting, the control group occupied an intermediate position in the rank-orders.

*295\161\2*

As we said earlier, everyone was asked three routine questions: how he got along, during his middle teens, with his father, with his mother, and with which parent he got along better.

Concerning adjustment with the father, we again see that better adjustment characterizes those whose sexual activity was with older female partners and of a voluntary nature. Poor adjustment is associated with homosexuality, force, and very young sexual partners. More than half the control group and the prison group had a fairly good father relationship, but they are outstripped by the heterosexual offenders vs. adults and minors and by the incest offenders vs. adults. Oddly enough, the exhibitionists, despite the fact that they do not use force and usually expose to postpubescent females, had a rather poor relationship with their fathers. The homosexual offenders had the worst of any class of sex offenders. This discovery would delight psychoanalysts more were it not for the fact that the homosexual offenders got along rather poorly with their mothers also.

The picture in regard to the modier is similar: good adjustment is associated with having unforced sexual relationships with postpubescent females, especially adult females. Poorer adjustment is associated with the use of force, with very young partners, and with homosexual offenses. The control group and the peepers share a rather good maternal relationship but the prison group got along only indifferently (though not poorly) with their mothers. The three groups showing the best adjustment with the mother are the same three who had the best adjustment with the father—the heterosexual offenders vs. adults, the heterosexual offenders vs. minors, and the incest offenders vs. adults. Lastly, it is worth noting that in all groups there is a better adjustment with the mother than with the father.

In answer to our question whether the interviewee got along better with his father or mother, some named one parent, but many replied that they got along equally well with both. Having the largest percentage impartial and the smallest percentage preferring the father seems to constitute a “normal” ratio in that it typifies the control group, the prison group, and the heterosexual offenders with postpubertal females.

Having the percentage who preferred the mother larger than (or equal to) the percentage who were impartial is associated with offenses that society looks upon as either very reprehensible or as in dicative of mental or emotional pathology. This mother preference is found in all the homosexual offenders, all the heterosexual aggressors, the exhibitionists, and in one of the three groups of incest offenders. Significantly, the one incest group with the “normal” ratio is the incest offenders vs. adults. The mother preference of the homosexual groups, the exhibitionists, and incest offenders vs. children seems chiefly the result of their very poor adjustment to their fathers rather than the result of a good adjustment to their mothers.

No group placed the father first. In fact, a relatively high percentage of father preference seems a bad omen. The four groups who preferred the father least include the control group, the peepers, the heterosexual offenders vs. adults, and the heterosexual offenders vs. minors. The six groups who expressed the greatest father preference include the three aggressor groups, two incest-offender groups, and the exhibitionists.

Interestingly enough, getting along very well with one parent generally involved getting along equally well with the other so that impartiality results. Note; that the groups typified by good relationship with the father are the same groups that had a good relationship with the mother also, and claimed they got along equally well with both. Such fortunate people were seldom subsequently convicted of sexual offenses involving violence, children, homosexuality, or exhibition.

*257\161\2*

Since the youngest or the only child is frequently favored by the parents, it is no surprise to find that peepers had relatively good relationships with their fathers. The same is true of their maternal relationships, in which they are very similar to the control group.

Perhaps the good relationship with both parents in part accounts for the fact that more of the peepers than any other group named them as their major source of sex knowledge: nearly 11 per cent of the peepers reported thus.3

In answer to the question, “With which parent did you get along better?” 52 per cent of the peepers reported that they got along equally well with both, 38 per cent preferred the mother, and 10 per cent the father. This is the “normal” preferential pattern that characterizes the control and prison groups and also the heterosexual offenders (not aggressors) against females of twelve and over.

Fifty per cent of the peepers came from broken homes; this is a low figure among sex offenders; only two sex-offender groups have a lesser one. As is usual, the original breakup of the home occurred prior to the boy’s tenth year; for the average boy it happened when he was 5.6 years of age—the fourth youngest age of any reported by our comparative groups.

Ordinarily a low percentage of broken homes is indicative of a good interparental relationship in both the original and subsequent marriages, but this does not seem to be true in the case of the peepers. Their parents got along rather poorly, less well than did the parents of the control group. Their low-middle position on this scale would call for no comment were it not for their better than average relationships with their parents and their relatively low percentage of broken homes.

Largely in consequence of the low percentage of broken homes, a sizable proportion of peepers lived 15 or more years in a home in which both a husband and wife were present: they rank third in this respect, below only the control group and the incest offenders vs. adults. Among those who lived 18 or more years with two parents the peepers are second only to the control group. Conversely, of all groups, the peepers counted the fewest individuals who lived in an all-female household.

Although they got along well with their parents, they did not socialize well with children of their own age. At ages ten to eleven only 16 per cent had numerous boy and girl playmates—near the bottom of the rank-order. In terms of female companionship, 41 per cent had no girl playmates and only 16 per cent had many, making the peepers as a group next to the lowest in this respect. Perhaps this correlates with their relative lack of sisters. This very poor socialization with females at an early age proves an ill omen for their future heterosexual adjustment.

Despite this poor socialization, the peepers have a moderate incidence of prepubertal sex play. The only noteworthy thing about them is their impartiality between the heterosexual and homosexual: equal numbers had experience in each. Moreover, the percentages who were exclusively homosexual and exclusively heterosexual in their play are essentially the same. Whether hetero- or homosexual, the sex play of the peepers was relatively limited: in close to half of the cases it was confined to one year.

A study of their techniques reveals that in heterosexual activity the peepers were low in the percentage with coital experience, but high in the percentage with mouth-genital contact. The latter percentage, however, may be insignificant since many groups lie within a percentage point or two of one another, and the percentages are all low. In homosexual techniques the peepers rate above-average in all, and the percentage with homosexual mouth-genital contact is exceeded only by that of the homosexual offenders vs. adults. This fact tends to confirm the high standing of the peepers in heterosexual mouth-genital contact. This homosexual emphasis is relative only; in absolute numbers more peepers had prepubertal coitus than homosexual anal relationships or homosexual mouth-genital contact. Of those who had prepubertal coitus only a very small proportion (20 per cent, the smallest proportion recorded) continued to do so uninterruptedly into postpubertal life; the majority ceased and did not resume having coitus for a number of years.

In summary, the future peepers had few girl companions, but an average number did succeed in having hetero- and homosexual play in preadolescent life. This play was relatively limited in duration. Compared to other groups, they emphasized mouth-genital contact, particularly in homosexual relationships.

Very few prepubescent peepers were approached sexually by adult females, equaling the percentage displayed by the control group. By itself this information signifies little, especially since adult females rarely have sexual contact with preadolescent boys but as another bit of data in the growing evidence of the peepers’ inadequate heterosexual adjustment it deserves at least passing notice.

A moderate number of peepers had homosexual overtures and physical contact with adult males; there is nothing distinctive about them in this respect, although in this instance the peepers, usually near the control group in many measurements, far exceed the controls.

Neither is there anything marked about their health during childhood: in an evaluation of this, they are near but somewhat inferior to the men in the prison and control groups.

Their prepubescent record of masturbation similarly reveals nothing unusual, except that in comparison to other offenders they tended to begin later in preadolescence.

*218\161\2*