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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The organisms that cause MPC are transmitted through sexual contact with a partner who is infected. This is generally through genital contact, although it may be possible for women who have sex with women to transmit these organisms through sex toys. Genital rubbing, without penetration, may also be sufficient to transmit the herpes virus from one partner to another.

A man or woman performing oral sex on a woman probably does not transmit gonorrhea, chlamydia, or the bacteria that cause nongonococcal urethritis since there is no direct contact with the cervix, although genital herpes infection with the cold sore type of herpes virus (type 1) can occur through oral sex. The use of dental dams or plastic wrap may help prevent such infection.

Condoms, if they are used properly and do not break, effectively prevent transmission of the bacteria that cause cervicitis (such as chlamydia and gonorrhea), as well as such protozoa as trichomonas,

the section on pelvic inflammatory disease).

through vaginal intercourse. However, herpes simplex virus may be transmitted even with the use of condoms.The cervical cap and diaphragm, used with the spermicide nonoxynol-9, also may help prevent such bacterial infections as gonorrhea and chlamydia, but condoms are still the best method of protection.

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When the virus comes out to the skin after the initial infection, it may cause symptoms or shed horn any area on the skin supplied by the nerve that is infected. For example, a person with oral herpes infection can experience a cold sore or shedding of the virus in any area on the face, but most commonly between the nose and the chin, and usually around the mouth. Although oral herpes may (rarely) cause symptoms on the gums and hard palate, sores inside the mouth are usually not the result of herpes infection. Aphthous ulcers, the painful ulcers that occur inside the mouth, are not cold sores; it is not clear what causes them, but they are very common and not serious.

Genital herpes infections can occur in any part of the body supplied (reached) by the infected nerve, but they most commonly occur in the genital area, including the pubic hair region, the groin, and (for men) the penis, scrotum, and urethra, and (for women) the labia, urethra, vagina, and cervix. Genital herpes outbreaks can also occur on the anal area and part of the buttocks. If someone has always had outbreaks in one area of the genitals, such as on the labia, and then has a recurrence on the buttocks, she may worry that she has somehow “spread” the infection herself. What has actually happened is that the virus took a different path along a nerve root during that outbreak, causing symptoms to appear in a different spot. Furthermore, people often shed the virus from many of these regions during an outbreak. A lesion on the penis, for example, is obviously shedding virus, but virus may also be found on the testicles and anal area at that time. Asymptomatic shedding can occur from any skin area that the nerve supplies.

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Prostatitis, too, can be caused either by sexually transmitted or by nonsexually transmitted bacteria. Younger, sexually active men are more likely to have prostatitis from a sexually transmitted cause (such as bacteria that cause gonorrhea, chlamydia, or nongonococcal urethritis), and older men are more likely to have prostatitis from a nonsexually transmitted bacterium such as Escherichia coh, although older men who have unprotected sex with a new partner can develop a sexually transmitted prostate infection. As discussed previously, older men are more likely to have benign prostate enlargement, which predisposes them to UTIs. Prostate infection can result from urethral infection, bladder infection, or possibly seeding of the prostate with bacteria that are transmitted through the blood. Bacterial prostate infections can become chronic.

Some prostate inflammation is not caused by bacteria but rather by viruses, fungus, trichomonas, or tuberculosis; there are also other possibilities that are not yet well understood. Prostate pain does not necessarily indicate prostate infection. Before antibiotics became available, prostatitis was a common complication of urethral infection with sexually transmitted bacteria. Now the likelihood of developing prostatitis after a sexually transmitted urethral infection is about 1 percent. Prompt treatment of bacterial urethritis further decreases the chances of this happening.

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Lack of self-esteem can be a big problem in sexual communication. For example, a person with low self-esteem may be more vulnerable to being bullied by a sexual partner into doing things that he or she doesn’t want to do. If a partner says “You would have sex with me if you loved me” or “If you don’t have sex with me, it means you’re frigid,” a person with low self-esteem may do what the partner wants instead of being able to recognize these lines for what they are: unfair pressure to have sex. A person who lacks self-esteem may feel that he or she doesn’t even deserve to express his or her needs, much less insist on having those needs honored. There are those people who feel so bad about themselves that they may think they deserve to become infected if it happens, so they don’t protect themselves at all.

By practicing what to say in different situations, you can pre- your feelings of low self-esteem and who is unwilling to change, think about finding a new partner. You may also want to think about seeking counseling, to sort out why you feel that you don’t deserve to have your needs met. There are also self-help books that may enable you to begin developing a better sense of yourself and becoming more confident and assertive in your relationships. By learning to care for yourself and about yourself, you can learn to make smart decisions, and thus keep yourself healthy.

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Pelvic inflammatory disease. PID is an infection of the uterus, Fallopian tubes, ovaries, or all of these structures, and it is usually caused by sexually transmitted bacteria such as gonorrhea and chlamydia. These bacteria cause inflammation of the cervix, and then they, as well as vaginal bacteria, may move through the cervix up into the pelvic organs. Pelvic infection may also be caused by a complication of pregnancy such as incomplete abortion or by bacteria introduced during gynecological surgery. The consequences of PID can be severe; for example, scarring can lead to chronic pelvic pain, infertility, or a tubal pregnancy. There may be other symptoms of infection—such as discharge, spotting between periods or heavier than usual periods, fever, chills, and nausea—or pain may be the only symptom.

Pregnancy in a Fallopian tube (ectopic pregnancy). When a fertilized egg becomes implanted in the Fallopian tubes instead of in the lining of the uterus, there will be pain, and the tube may rupture, causing significant bleeding and possibly even death. Any sexually active woman with pelvic pain should promptly seek medical care to rule out this medical emergency.

Trichomoniasis. Although trichomoniasis, a vaginal infection, does not usually cause symptoms higher up in the genital tract, occasionally pelvic pain occurs with trichomoniasis for unclear reasons. The other, more common, symptoms of trichomonas infection—such as inflammation and itching of the vulva, discharge, and a fishy odor—may also be present.

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The word “pornography” means “the writing of prostitutes.” The word comes from the way prostitutes advertised their services by writing their names and addresses on walls in ancient Rome and Greece. Pornography refers to any picture or writing that is meant to be sexually arousing. To many people, pornography is offensive and indecent. However, some people distinguish between pornography and erotica, which are sexually arousing pictures or writings that do not offend the average consumer.

“Soft-core” pornography is also distinguished from “hard-core” pornography. Soft-core pornography depicts naked bodies, including genitals, and limited sexual activity. Hard-core pornography depicts sexual intercourse and sex organs more graphically and more exclusively. It may also include violent sexual acts or other unusual behavior, such as sex with animals. Hard-core pornography is more likely to be considered obscene.

Although the First Amendment to the U.S. Constitution protects the right of free speech, the U.S. Supreme Court has always stated that obscenity is not protected because obscenity is not speech. Over the years, the Supreme Court has struggled to define obscenity.

In the 1973 case of Miller v. California, the U.S. Supreme Court issued a legal definition of obscenity, which is the standard still used today. The court found that a writing or picture, when taken as a whole, is legally obscene if:

• it appeals to a prurient—lascivious or lustful—interest in sex

• it offends the standards of the community in which it appears

• it has no serious literary, artistic, political, educational, or scientific value

If materials are legally obscene, then laws that ban their sale can be constitutionally upheld. In 1969, the U.S. Supreme Court ruled that a person could privately possess obscene material without committing a crime. But in 1990, the court ruled that private possession of child pornography is illegal and is not protected by the US. Constitution. Child pornography depicts children in sexual poses or engaged in sexual activity.

This controversy concerning whether sexually explicit material can be banned grows out of the 1873 Comstock Act that made it illegal to transmit any “obscene, lewd, lascivious, indecently filthy, or vile article” through the U.S. mail. The censorship that Anthony Comstock imposed on American society has had long-lasting and far-reaching effects.

The Supreme Court definition of obscenity remains vague in many ways. It continues to be challenged by people who advocate complete, unrestricted freedom of speech, and it is challenged by people who want greater restrictions.

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UTI (urinary tract infection) is caused by bacteria that have spread from the rectum to the vagina or penis and then to the urethra and bladder. UTIs may be sexually transmitted. They include infections of the bladder (also called cystitis), the ureters (the tubes that lead from the kidneys to the bladder), and the urethra (the tube that carries urine from the bladder to outside of the body). Severe cases, left untreated, may cause kidney infection.

Common Symptoms

• burning pain during urination

• the urge to urinate when the bladder is nearly empty

• a frequent urge to urinate, especially at night

• involuntary loss of urine

• lower abdominal pain

• blood and pus in urine

• fever

UTIs are very common in women and men who are sexually active. They affect women more often than men because a woman’s urethra is shorter than a man’s, and bacteria may get into the bladder more easily. A woman’s urethra is also closer to the anus than a man’s.

How UTIs Are Spread: Any kind of sex play that brings fecal material into contact with the vagina and urethra. Unprotected anal intercourse carries a very high risk for urinary tract infection.

Diagnosis: Consult your clinician to confirm diagnosis and treatment. Some women who use a diaphragm are susceptible to frequent UTIs. Adjusting to the bacterial environment caused by having new partners may lead to a bladder injection called honeymoon cystitis.

Treatment

• antibiotics

• Pyridium, which may relieve symptoms but will not cure the infection

Protection: To prevent urinary tract infections or discourage them from returning:

• Drink eight or more glasses of water a day. Avoid soft drinks, which can promote the growth of bacteria.

• Drink unsweetened cranberry juice.

• Urinate immediately before and after intercourse.

• Avoid using a sexual position that seems to trigger UTIs.

• Keep the pubic area clean and dry.

• Use condoms or vaginal pouches during vaginal or anal intercourse.

• Wipe from front to back after bowel movements and urinating to avoid the spread of bacteria to the urethra.

Some women who are susceptible to frequent UTIs take antibiotics to prevent infections when they have sexual intercourse.

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Intimacy is the closeness and familiarity we feel as we share our private and personal selves with someone else. It is the foundation of our most personal relationships with other people, whether or not the relationships are sexual.

Intimacy is based on trust. It is another gift our parents can give us. If we are cuddled as infants, if we are treated with respect and grow up in an environment with healthy attitudes about sex, and if we learn to trust that the people closest to us will not hurt us, we can more easily develop the ability to be intimate with our sex partners, as well as with other people. If we are able to be intimate with our sex partners, we will be able to share our feelings, express our desires, make healthy compromises, and disagree with them without fear. We will also be able to appreciate their feelings and point of view.

Many women and men discover that they are unable to be as intimate with their sex partners as they are with other people in their lives. They may find that they are unable to enjoy sex as much with someone with whom they are intimate. This kind of sexual inhibition can be very damaging to long-term relationships like marriage. Inability to be intimate with a sex partner can result from sexual inhibitions that are associated with body image, self esteem, and internalized homophobia. Women and men with highly developed social skills may still be unable to be intimate. Problems with intimacy can be treated with psychotherapy.

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The major accentuation of the sex differences in external appearance is brought about by the development of secondary sexual characteristics. The typical sequence of events has been described by Marshall and Tanner. In girls, the first sign of puberty is usually the appearance of “breast buds,” that is, an elevation of the breast and nipple as a small mound, with the areolar diameter enlarging over the infantile status. In some girls, the appearance of pubic hair precedes breast budding, but in the majority it follows. Axillary hair typically appears about two years after the start of pubic hair growth. More or less concurrently with the external changes, internal sexual structures, including the uterus, grow and mature also. Uterine development probably will have reached a definitive stage for menarche, the first menstrual period, to occur, usually after the peak of the height spurt has been passed. However, menarche by itself does not signify the attainment of full reproductive capacity. Early menstrual cycles are often anovulatory, that is, do not produce fertile eggs, and postmenarcheal “adolescent sterility” may last from one year to eighteen months.

On the average, pubertal changes in boys begin only about six months later than in girls. The general impression of an overall, considerably earlier maturation of girls is largely due to the fact that the growth spurt (with its concomitant somatic changes) is placed earlier in the sequence of pubertal changes in girls than in boys; the average boy has his growth peak two years later than the average girl. The earliest sign of pubertal changes in boys is a growth acceleration of testes and scrotum, often accompanied by the thinning and reddening of the scrotal skin. Simultaneously or shortly after, pigmented pubic hairs start to appear. About a year later, spurts in penile growth and height begin. Coinciding with the penile growth spurt, the male internal sexual structures, for instance, the seminal vesicles and the prostate, enlarge and develop. Their maturation is the prerequisite for the first ejaculation of seminal fluid which tends to occur about a year after the beginning of accelerated penile growth. Approximately one-third of all boys show a distinct enlargement of the breasts around the middle of puberty, which usually regresses after about a year. About two years after the onset of pubic hair growth, axillary hair appears; there is also an increase in axillary sweating due to an enlargement of axillary sweat glands. At about the same time, facial hair starts to grow. It usually begins at the corners of the upper lip, then spreads out to form the mustache, later extends to the upper part of the cheeks, and finally forms the beard. More toward the end of the growth spurt, the voice breaks and deepens, often very gradually. Starting in adolescence, the hairline above the forehead recedes; this process becomes more marked in adulthood.

For clinical and research purposes, several scales for the normative characterization of pubertal status have been developed. Most widely used are Tanner’s photographic and descriptive standards of breast and pubic hair development in girls, and genital and pubic hair development in boys. The standards comprise five stages. (There is a sixth stage of pubic hair development in 80% of the males and 10% of the females.) Stage 1 is always prepubertal, stage 5 (and 6) adult. Tanner has published centile standards for age ranges of pubertal developmental stages.

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