Herbal Health

During a routine Pill check consultation the patient mentioned that she had experienced painful intercourse since the birth of her baby six years previously. She believed that she had been ‘ripped’, and that the stitches had come undone. She had already consulted two gynaecologists who were loathe to undertake any surgery as she appeared well healed. As the doctor looked at the healed but scarred perineum, noticing the scar tissue was a lighter and pinker colour than the slightly pigmented skin on either side of it, the patient said that she had looked at it in the mirror and there was no ‘space’ between the front and back passages. What she seemed to be saying was that the vagina and rectum felt to her to be joined, with no wall between them. It is interesting that she had also been complaining of a lot of wind which she felt was ‘getting in from below’. There was a sense that air was getting from the rectum to the vagina and thence ‘to the insides’.

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The consultation was first broken down into phases in work done in Manchester, where nearly 2000 audiotaped consultations were analysed (Byrne and Long, 1976). Six phases were defined which appeared frequently to follow each other in sequence, but the emphasis was still very much on the doctor .

Next the consultation was viewed from the angle of maximizing the potential of each consultation, and not just dealing with the presenting problem and getting the patient out through the door (Stott and Davis, 1979). This important work described how other key elements of care, such as the management of continuing problems and opportunistic health promotion, could be raised when appropriate. However, it did not help doctors to understand where they were in the progress through a consultation.

1. The doctor establishes a relationship with the patient.

2. The doctor either attempts to discover or actually discovers the reason for the patient’s attendance.

3. The doctor conducts a verbal or a physical examination or both.

4. The doctor, or the doctor and the patient, or the patient (in that order of probability) consider the condition.

5. The doctor, and occasionally the patient, details treatment or further investigation.

6. The consultation is terminated, usually by the doctor.

The Byrne and Long consultation model (1976).

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The patient with a physical ailment is a whole person with feelings about that disability or disease. Feeling less of a woman or man because of the development of illness may profoundly affect sexual responsiveness and desire. A woman who has had an operation which she regards as mutilating (removal of a breast, or an abdominal scar) may be fairly easy to identify; one whose feeling of damage is concealed (for example, after a cone biopsy or removal of an ovarian cyst) may be more difficult. Patients after any illness or surgery may grieve for their previous good health or completeness and find sexual responsiveness inhibited.

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For such women there is usually no conscious desire for a baby, and they need a reliable method of contraception, but one that can at the same time allow them to fantasize about the possibility of pregnancy. If such a method can be found their sexual responses are likely to remain intact.

Men can have fantasies and feelings about what the operation of sterilization does to the woman, and again these can be difficult to elicit.

A pale and withdrawn woman in her early 30s was referred for counselling as she was unable to allow intercourse. There was a long and sad history of personal tragedy culminating in hysterectomy at 28 years for uncontrolled menstrual bleeding. Following this, the woman had become more and more unhappy, had retreated into a fantasy life of romantic fiction, and when first seen, sat behind a veil of unkempt hair.

It became clear that her partner was angry and unsympathetic, and that he was engaged in a long and serious sexual affair with a colleague. It took many hours of listening before he was able to state that in his opinion, a sterilized woman was by definition a useless sexual partner, and he could see no way forward in his marriage. In fact, once both partners had identified the underlying anger on either side, there was an improvement in their situation and a marked gain of confidence in the wife, who managed to pick up the threads of her life again.

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The attitudes of professionals to different cultural customs change as the views of society change. A legacy of Christian moral imperialism that parallelled colonialism has been succeeded by an agnostic, generally liberal tendency towards non-interference. Lack of absolutism has, on the whole, got rid of the view that non-Christian cultures are heathen, but not replaced that certainty with very much to rely on when faced with a cultural dilemma. Modern western doctors may see themselves, and probably most of their patients, as culturally neutral, perceiving problems only with ethnic minorities and Roman Catholics. That we are not so bland is demonstrated by the intense national debate that takes place whenever events bring ethical decisions concerning reproduction to public notice. We have not yet become, in Britain, the culture of the pre-eminence of individuality. We need to be aware of the relativism of our culture when working in a transcultural setting.

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As we noted in the section describing the vital statistics of the sample, there are substantial differences in the proportions of the patterned and incidental offenders who married. At one extreme are the incest offenders, all of whom married, and at the other the incidental peepers, of whom only 29 per cent married. A comparison shows that the proportions who married were essentially the same for three of our six groups: more patterned offenders were married in two groups, and in the remaining group more incidental offenders had married. These differences are in part explained by age: in every instance the group with the larger proportion of ever-married men is also the older group. Nevertheless, the differences are too large to be thus accounted for, being 20 percentage points or more. In two groups the patterned offenders have the most married men and in one group the incidental offenders lead.

The patterned offenders were more likely than the incidental offenders to have had premarital coitus with the girl they first married. This is true of four groups, and the percentages in the remaining two are essentially the same.

The length of time devoted to foreplay seems not to differ between patterned and incidental offenders in any meaningful way.

Mouth-genital contact was a diagnostic variable outside of marriage, and it proved to be so within marriage as well. In every group more patterned offenders had experienced mouth-genital contact with their wives than had the incidental offenders. For the latter the percentages range from 13 to 70, while for the former they are 47 to 72 per cent. Similarly, substantially more of the patterned offenders (roughly one third to two thirds) had experience in both fellation and cunnilingus with their wives. This orality seems to typify patterned offenders regardless of marital status.

While we realize that a husband’s report on how often his wife reaches orgasm in coitus is frequently grossly erroneous, we nevertheless compared the patterned and incidental offenders on this point. Without exception the patterned offenders reported greater orgasm frequency for their wives, though the differences were sometimes small.

The proportion of males who had extramarital coitus was larger among the patterned offenders than among the incidental in four groups, and the one instance where the reverse was true was the case of the homosexual offenders whose patterned individuals are far more homosexually oriented than the incidental. Perhaps we see here some indication of inability to resist impulse.

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The age of the offender at the time of the offense ranges from the established minimum of sixteen years (43 cases) to those who were in their seventies (11 cases). The large majority of offenses, however, were committed by men who were in their twenties and thirties. At the time of the crime the age of the median offender in each of the 14 types of offenses ranged from twenty-three to forty-six years. There are some clear-cut trends. Expectedly, the three father-daughter incest groups, with their age determined to a degree by the age of the daughters, arc three of the oldest offense groupings. The only other group to match them is the offenders vs. children, in which the median age at offense is slightly higher than that of the lowest of the incest groups.

A number of interesting relationships between age and offense may be noted. Offenses with or without force against female children are committed by relatively older males, whereas the offenses against minor girls, either with or without force, were committed at much younger ages, and a fair proportion of them by males who were not too different in age from the girls. The median age figures are strongly supported by the per cent figures in the various age classes.

Secondly, in the offenses in which force was used, the males were consistently, on the average, younger at the time than those in the matching nonforce offenses.

The three homosexual groups appear more uniform in respect to age than do the heterosexual-offender or aggressor groups. The homosexual triad show only a narrow difference of three and a half years in the median age at which the offense was committed. While the homosexual offenders vs. children were not so old as the heterosexual offenders vs. children or the aggressors vs. children, they tend to group in the late twenties and early thirties when tabulated year by year. This is in contrast to the two other homosexual-offense groups which clearly peak in the twenties and begin to taper off by the thirties. Thus there is a suggestion of the same age discrepancy between object and offender that is found in heterosexual pedophilic offenses, even though the median age does not reveal it.

When the median ages (at time of offense) of the heterosexual and homosexual offenders vs. minors are examined it is clear that the homosexual offenses were committed by older men, the median man being thirty-three while the heterosexual offender was twenty-five. Among the heterosexual and homosexual offenses vs. adults this age contrast appears to be lacking. The median age as well as the distribution in the four age classes of the males who committed these two types of offenses appear very similar. However, when the adult objects of the offenses are subdivided into three age groups we see the homosexuals who offended against sixteen- to twenty-year-olds were older than the heterosexual offenders.

Eighty per cent of the heterosexual offenses against adults aged sixteen to twenty occurred before the offender was thirty, while 70 per cent of the homosexual offenses against adults of the same ages were committed when the offenders were over thirty. Moreover, as the age of the adult victim of the heterosexual offense increases, so does the age of the offender. Thus for victims over twenty-six, 90 per cent of the offenses were committed by males over thirty years of age. But this process is reversed for the homosexual offenses, with 71 per cent of the offenses against persons aged twenty-one to twenty-five and 68 per cent of the offenses against persons aged twenty-six or older occurring when the offender was under thirty.

This finding is partially an artifact of the police policy of arresting both males discovered in adult homosexual activity, but it also shows the contrast in age preference between the heterosexual and homosexual domains. The choice in heterosexuality is governed by many norms of appropriate behavior, the bulk of which proscribe sexual contact with anyone below a certain age, but which also seek to control the relative ages of the adults. Thus the aging heterosexual male chooses older sexual partners, and while he may prefer women no older than thirty, in general his practices conform to social custom. The aging homosexual, being already outside the realm of approved behavior, is not so subject to society’s views on age of partner.

The preference for younger males leads to instability in homosexual “marriages,” and the problem of the maturing homosexual is a very special one. As he becomes older and often less physically attractive to younger men, he frequently has difficulty in finding partners who are both desirable and suitable. As a consequence he tends to seek late teen-age boys who are often willing to accept pay or favors in return for sexual contacts. There may be considerable danger in these contacts because of the unpredictability of the boys. In some cases the tables are turned and the sought-after young man becomes the offender and the older man the victim. One of our cases, which involved the murder of a fifty-five-year-old business man during his second contact with a drifter he had picked up, is relevant. The price was not right, and in a fury of indignation which occurred in an alcoholic daze the nineteen-year-old stabbed the older man in the throat with a kitchen knife and fork.

The ages at which peeping and exhibition offenses are committed differ widely. The peeping offenses are generally carried out by a younger male, and appear to peak when the offender is eighteen, twenty-four, and twenty-eight. The exhibition offenses, on the other hand, show a median offender who is about six years older, and the number of convicted offenses builds up from ages twenty-two to twenty-nine, and again in the middle thirties, but not so strongly.

In summary, it seems clear that males whose heterosexual offenses, both force and nonforce, are directed against children tend to be older than those who become involved with minors or adults. This trend is less marked in homosexual offenses. A second finding is that offenses in which force is used are committed by younger offenders than are the comparable nonforce offenses. Third, when one examines the age distributions of the offenders and the adult objects of their offenses first in heterosexual and then in homosexual offenses, it appears that as the heterosexuals become older the age of their partners increases correspondingly, whereas the aging homosexual is more apt to seek youthful partners.

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The above percentages do not, of course, measure the amount of extramarital coitus. One quantitative measure is the number of partners accumulated by those who had extramarital coitus. A rank-order of number of partners does not agree with the incidence figures discussed on the previous pages. The discrepancies are sometimes quite startling. For example, the homosexual offenders vs. adults ranked last in ever-never incidence of extramarital coitus, but those who had this experience had it with the second largest number of partners. Setting aside the calculations of numbers of extramarital partners for the entire sample, and considering only the eligible category, one sees no particular groupings or tendencies. The aggressors vs. minors rank first with 12 partners, the homosexual offenders vs. adults are second with 11, and the prison group is third with almost as many. The control group falls in the central portion of the rank-order with five partners.

Although a number of variables are obviously involved, one can posit some explanations. If one has an aggressive, sexually active group (such as the aggressors vs. minors), one may expect a high incidence of extramarital coitus and a large number of partners; such a group could be said to have a low threshold for extramarital coitus. A group with a high threshold (due to morality, homosexuality, and other deterrents) would provide a low incidence, but those with enough drive to cross the threshold would express this strength of drive by accumulating a large number of partners. Such seems the case with the homosexual offenders vs. adults. The above explanations cannot serve for the majority of groups whose paradoxical figures remain inexplicable. Those with the fewest extramarital partners are the heterosexual

aggressors vs. adults (the median individual had nearly five partners), the incest offenders vs. children (four partners), and the peepers (three partners). The peepers require no explanations: their life, or any segment of it, reveals difficulty in securing coitus. The other two groups, however, present a real problem. First of all, the incest offenders vs. children had the largest proportion (84 per cent) of ever-married members who reported extramarital coitus—why, then, did they have so few partners? Their heterosexual life in general suggests no especial deterrents; they are ordinarily not a group notable for restraint. There is nothing in the number or duration of their marriages to explain this paucity of partners; indeed, a high percentage (50 per cent) reported their marriages as unhappy, a situation which usually breeds extramarital coitus. A high incidence, a small number of partners (an average of four), and rather steady frequencies of extramarital coitus indicate a certain adulterous monogamy such as one would find among men who confine their sexual activity outside their marriages to longtime mistresses. Despite the suggestion of stability and contentment implied by such monogamy, the extramarital experience obviously did not prevent these men from ultimately turning toward their prepubescent daughters.

The same mystery obtains with the heterosexual aggressors vs. adults, a group who were ordinarily quite effective in securing coitus and obviously not above using force in order to do so. They also had a relatively large proportion (77 per cent) with extramarital coital experience. One hint we have lies in the nature of the marriages of these aggressors vs. adults: a large proportion (about two thirds) reported their marriages were happy—a situation that does not preclude adultery, but one that might limit the number of partners. Another possible explanation is the small number of years they were married: only 30 per cent (a low figure) of their years of life since puberty and outside prison were spent in the married state, consequently they had less time than most in which to build up their number of extramarital partners. In this connection one should realize that a man who has a forced sexual relationship with an adult female is apt soon thereafter to have his opportunities for additional extramarital experience abruptly curtailed by the police.

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Virtually all the males of our comparative groups had, at some time in their postpubertal lives, reached orgasm through self-masturbation: the percentages range from 92 to 100 per cent. Obviously such a universal phenomenon does not lend itself to comparative study on an “ever vs. never” basis.

The accumulative incidence, the percentage with masturbation experience by a given age, is likewise not a good comparative criterion because the range is so small. For example, 80 per cent or more of all groups had masturbated by age twelve. About all that can be said is that the aggressors and homosexual offenders vs. minors and adults tend to have, by any given age, more of their members experienced in masturbation than do other groups. This is particularly true of the homosexual offenders vs. adults who reach die ultimate 100 per cent mark by age twenty-one.

The age at which the first masturbation with ejaculation occurred (i.e., the age at first postpubertal masturbation to orgasm) closely parallels the age at puberty. In brief, males who reached puberty early had similarly early masturbation. For example, the median homosexual offender vs. adults reached puberty at 13.1 years of age, and ejaculated by masturbation at 13.3 years of age. This close correspondence is inevitable since the ability to ejaculate is a major criterion in establishing the age of puberty, and masturbation is the prime source of first ejaculation. However, the correspondence is less with increasing age at puberty: the median incest offender vs. adults, for example, reached puberty at 14.5 years and ejaculated in masturbation four months later at age 14.8. The differences in median age at first postpubertal masturbation are ordinarily small: a one-year span, from age 13.3 to 14.3, includes all gr6ups save two, the incest offenders vs. adults and the heterosexual offenders vs. minors whose medians are 14.8 and 14.5 respectively.

Age-specific incidence, the number with masturbation experience within a given five-year age-period, was calculated excluding all time spent in prisons or other closed institutions. Consequently, the presence or absence of masturbation as evidenced by our incidence figures is not influenced by involuntary isolation from society.

The general tendency among the single males is toward progressively lower age-specific incidence after the teens. From puberty to fifteen, when sociosexual activity is not well established, the incidences are high, all being above 70 per cent. In the next age-period, 16—20, the incidences remain high or even increase, owing to the addition of individuals who did not reach puberty until sixteen or later. From twenty on, however, the incidences decrease as sociosexual activity displaces masturbation and as the imperativeness of the sexual drive lessens. This is most dramatically seen in single; males of the prison group whose age-specific incidence falls from 88 per cent in age-period 16-20 to 67 per cent in age-period 21-25, then to 62 per cent, and finally to 46 per cent in age-period 31-35.

On the other hand, a few groups—chiefly the homosexual offenders and the peepers—resist this trend and maintain high incidence figures. Consequently, with some groups maintaining high incidences and other groups having decreasing incidences, the range among all groups widens: in age-period 16-20 it was from 76 to 98 per cent while in the following period it was 47 to 94, and still later 44 to 97 per cent. The resistance of the homosexual offenders to a reduction in incidence simply illustrates the important role that masturbation plays in the lives of the majority of homosexual males, a topic which is discussed in more detail in the section on homosexual offenders vs. adults. In the case of the peepers, it would seem reasonable to assume that masturbation was a concomitant of voyeurism.

Age-specific incidence among married males shows a similar decline, coupled with an expansion of range. For example, in the earliest age-period, 16-20, the range is 23 to 60 per cent; in age-period 31—35 it is 8 to 60 per cent.

Again some groups resist the decline, among them the exhibitionists, the incest offenders vs. children, and the homosexual offenders vs. adults. All three, one will recall, had either high or moderately high incidences of masturbation in premarital life up to age twenty.

The significance of these age-specific data is diminished by the gross-ness of our measurement: one act in a five-year period suffices to place a person in the positive incidence percentage. One-year rather than five-year calculations arc merited, and we hope sometime to do this.

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The exhibitionists had a moderate record of juvenile convictions; only about one eighth having had this experience. The type and severity of their offenses were similarly unremarkable. This middle-of-the-road trend continued into adult life, when their incidence of convictions is also moderate: nearly one third had been convicted by age twenty, about three quarters by thirty, and nine out of ten by forty.

The average age at first conviction (23.9 years) and at first conviction for exhibition (26.5 years) is neither particularly young nor old.

However, in some other respects the exhibitionists are quite distinctive. Of all the sex offenders, the largest proportion (72 per cent) of their convictions were for sex offenses, and conversely the smallest proportion (28 per cent) were for nonsex offenses. This does not, however, mean that many exhibitionists confined themselves to sex offenses: the number of “pure” sex offenders is a moderate 53 per cent.

In terms of per capita convictions they are again outstanding. They are second only to the aggressors vs. children in the number of convictions (4.3) and rank first in the number of misdemeanors resulting in imprisonment (2.5). No other group approaches them in the per capita number of sex-offense convictions (3.12). With regard to what we term “specific” sex offenses—i.e., exhibition offenses for exhibitionists, rape of minors for aggressors vs. minors, etc.—the exhibitionists had by far the largest per capita number of specific sex offenses: 2.13. The peepers, who rank second in this respect, had only 1.61. In brief, the exhibitionists had committed more sex offenses (as measured by conviction) than any other group.

There is nothing unusual about the nonsexual criminality of the exhibitionists. They seemed equally disposed toward property offenses and vagrancy-disorderly conduct, each accounting for about one third of the nonsexual offenses resulting in conviction.

Some two thirds of their sex offenses were exhibition, a not unusual proportion. Of the nonexhibition sex offenses, most—about a third-were against willing or acquiescent females; some—almost a fifth—the same percentage as among the peepers, involved the use of force on unwilling females; the same number were a miscellany of less common types of sex offenses, and 16 per cent were peeping offenses. This record indicates the heterosexuality of their offense behavior, and by its odd diversity (a mixture of force, peeping, and statistically unusual offenses) also suggests a psychopathology that one would have anticipated in a group given in large part to compulsive exhibition.

This compulsiveness accounts in great measure for the fact that the exhibitionists are quite recidivistic. Relatively few (13 per cent) have only one conviction; about one third, the second largest proportion recorded, had four to six convictions; and they display the third largest percentage of those convicted seven or more times (16 per cent). A group that can boast more seven-time than one-time losers can be justly labeled recidivistic.

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