When BPH is suspected in a man with Parkinson’s disease, a doctor needs to be extremely conservative in treating the symptoms. The consequences of treating BPH symptoms in men with Parkinson’s disease are serious; in fact, one urologist believes, even persistent residual urine and recurrent urinary tract infections should not warrant a TUR in thisgroup of men. Still another complicating factor is that men with Parkinson’s disease are often taking several medications that can have significant side effects on the lower urinary tract.

So what to do? Probably the safest course of action is to start with an alpha-blocking drug, which works in two ways (a more thorough description appears earlier in this chapter): First, alpha blockers reduce resistance in the bladder outlet. They also decrease residual urine, and therefore the threshold for bladder instability and irritative symptoms. In Parkinson’s disease, the same factors that cause rigidity can affect the bladder’s ability to contract and the pelvic floor’s ability to relax when a man tries to urinate. One possibility, if this is happening to you, is to work with a physical therapist to learn techniques for relaxing your pelvic floor muscles, which might make urination easier.

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Other complications include epididymitis, if a precautionary vasectomy wasn’t performed during surgery; and bladder spasms (painful, uncontrollable contractions of the bladder, forcing urine out in spurts around the catheter)— which may be largely attributable to the presence of a catheter, and which should improve once the catheter is removed.

After the catheter is removed, some men may have trouble with stress incontinence—when urine leaks during certain physical activities, like running or playing golf. This may be temporary, and may resolve itself during the first few months after surgery. In rare cases, however, it is permanent, either as a result of damage to the urinary sphincter during the operation, or as the inevitable consequence of years of bladder damage, persistent bladder instability and urgency incontinence—when urine leaks as a man who urgendy has to go to the bathroom is trying to get there.

The most common aftereffect of open prostatectomy is retrograde, or “dry,” ejaculation. Impotence (difficulty achieving or maintaining an erection) may affect as many as 15 to 20 percent of men. (This is an unverifiable statistic; it’s tough to try to quantify impotence, because so many factors are involved. For more on impotence, see Chapter 8.)

Also seen, but rarely (in 2 percent of men), is a constriction of the bladder neck, called a bladder neck contracture, which is caused by scar tissue from the surgery. This can be reopened in outpatient surgery by a urologist. (Using a cystoscope, the urologist makes a few tiny cuts to relax the tight scar tissue.)

In rare cases, men may also develop a urethral stricture (scar tissue in the urethra). Most urethral strictures respond well to dilation—stretching the urethra, in one or two sessions. Stubborn strictures can also be treated with tiny incisions, like those done to ease bladder neck contractures.

*253\201\8*

The first bit of advice your doctor should give you here is, “Be patient.” Erections return gradually. Your body has been through a trauma; it needs time to recover. This doesn’t mean you should give up on sexual relations until the day you wake up with a full erection. Also, know that the erection you have two months after surgery is not necessarily the same one you’ll have two years from now. Most patients experience an improvement in their erections over time; the quality improves month by month.

Normally, men become sexually aroused, have an erection and then pursue sexual activity. But after radical prostatectomy, the stimuli that cause an erection are different; visual stimulation is not nearly as important as tactile sensation—what the penis can feel directiy. In other words, soon after surgery, the only way a man can achieve an erection is with direct sexual stimulation. This changes the sequence of events. Now, men need sexual stimulation to produce an erection sufficient for intercourse. For this reason, don’t be afraid to experiment with sexual activity—you can do no harm!

Also, if you have a partial erection, go ahead and attempt intercourse— vaginal stimulation will be the major factor that encourages further erections. So don’t wait until you have the “perfect erection.” (If you do, you could be waiting a long time and missing out on this important aspect of your life.) Use of lubrications such as K-Y jelly also will help tremendously.

At first, sexual stimulation is the major thing that produces erections in men recovering from radical prostatectomy, and because the best stimulation is vaginal stimulation, we encourage patients to use whatever erection they have to get vaginal penetration. Often they’ll notice that the erection soon becomes much firmer.

*216\201\8*

Estrogen does not cause hot flashes, although patients do develop the same problems with sexual function as men who are castrated (see “Surgical Castration,” above).

Conclusion: One milligram of DES a day is just as effective as higher doses, and one milligram of DES is just as effective as surgical castration in prolonging life.

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Radiation after prostatectomy is also used in some men who have “positive surgical margins”—if the edges of the removed tissue show cancer cells. However, there are several considerations here: One is that just because the surgical margins are positive does not necessarily mean that cancer is left behind. How can this be? When cancer reaches beyond the prostate to invade nearby tissue, it produces a dense scar tissue that acts, as one surgeon describes it, “like Super Glue.” As a surgeon removes the prostate, this thick scar tissue sticks to the surrounding cancer cells—picking them up like a lint brush. So in some cases, although the pathologist may see cancer cells at the margin—and make a judgment of “positive surgical margins”—there are no cancer cells left inside the patient; the sticky scar tissue took them all away.

A study at Johns Hopkins involved such instances, when a surgeon removed the prostate, looked at it, suspected that some cancer cells were present, went back and cut out more of the surrounding tissue. Even when the pathologist believed there was a positive surgical margin at the edge of the prostate, in 40 percent of these patients there turned out to be no cancer left behind in that adjacent tissue.

Another factor to consider here is that in patients with cancer that has extended beyond the prostate to the point where it is not possible for surgeons to remove it all, it’s a pretty likely bet that there are other cancer cells floating around elsewhere—that cancer has already escaped from this tissue near the prostate, that it has already metastasized. And that any attempts at local treatment (such as radiation to this area) will not be able to reach all the cancer. Finally, radiation after radical prostatectomy can make a man more prone to problems with urinary control and sexual function; the radiation may damage tissue already made vulnerable by the surgery.

*139\201\8*

We have previously noted that all homosexual offenders are characterized by having had poor relationships with their fathers between ages fourteen and seventeen; the homosexual offenders vs. minors have the misfortune to be the most extreme examples of this. Thirty-six per cent reported that they got along well with their fathers, but 39 per cent reported they got along badly. In short, of all groups the homosexual offenders vs. minors had the worst paternal relationship. The adjustment to the mother was better, but still below-average.

In regard to parental preference, they display the typical homosexual picture: 53 per cent got along better with their mothers, 33 per cent got along equally well with both parents, and 13 per cent had better relations with their fathers. This ratio is very close to that of the homosexual offenders vs. children. Maternal partiality is a feature shared by only a very few groups other than the homosexual offenders. Strangely, none of these mother-partial groups rate above-average in good relationship with their mothers; they cannot be regarded as “mammas’ boys.”

About 56 per cent of the homosexual offenders vs. minors came from broken homes; this is a higher figure than that for most sex offenders. As is the case of the other homosexual offenders, an unusually large proportion of the breakups occurred before the subject was five years old. On the other hand, a relatively large number occurred when the boy was ten or older; the homosexual offenders vs. minors had the second highest percentage in this age-category. The result is that the age of the average offender at the time of the breakup was 6.2 years— fairly early, but not extraordinary.

The parents of the homosexual offenders vs. minors did not get along with one another very well: half of them got along well but one third got along badly or poorly. Thus in a rank-order of parental harmony the homosexual offenders vs. minors are in fourteenth and fifteenth places.

Relatively few homosexual offenders vs. minors lived fifteen or more years in a home wherein both a husband and wife were present; 56 per cent did, but most other groups have higher percentages. Conversely, the homosexual offenders vs. minors rank high in the number of years lived in a household where the adults were all female.

With regard to companions at age ten to eleven, the homosexual offenders vs. minors had an excellent socialization with their contemporaries and particularly with girls, a happy situation that characterizes all homosexual offenders. In fact, the relatively large number and proportion of female playmates strikes one as faintly ominous when one recalls that at this age the average boy is apt to be disdainful of girls and avoids them. However, in most instances the number of girl companions was balanced by an equal number of boy companions, so that the over-all impression is one of excellent social adjustment.

Of all the groups used routinely in comparisons, the homosexual offenders vs. minors contained the largest number who had had prepubertal sex play (84 per cent). This, in terms of simple “ever vs. never” incidence, was rather evenly balanced between the heterosexual and the homosexual, 63 per cent having experienced the former and 68 per cent the latter. As one would anticipate, the homosexual offenders rank first, second, and third in a rank-order of percentages of those with prepubertal homosexual play, and the homosexual offenders vs. minors occupy the first rank. In terms of exclusiveness, somewhat more of them confined their sex play to boys than to girls, but the majority had play with both. The duration of their heterosexual play is in no way unusual, but they have the fourth highest percentage (57 per cent) who continued their homosexual play for three years or more.

An intermediate number of homosexual offenders vs. minors had prepubertal coitus, but (as is true of all homosexual offenders) the number with heterosexual mouth-genital contact is below average. Conversely, a relatively large number had homosexual masturbatory, oral, and anal experience.

In summary, one can say that the homosexual offender vs. minors is characterized by much prepubertal sex play that was more homosexual than heterosexual.

This homosexual orientation is seen in more striking form when one turns to the question of prepubertal sexual experience with adults. The homosexual offender vs. minors is intermediate, relative to other groups of sex offenders, in experience with adult females, but distinctive in experience with adult males. Proportionately more of them than of any other group received sexual advances from adult males (35 per cent), and in more instances (28 per cent) these advances led to physical contact. In this large quantity of experience with men they are like the other homosexual offenders, but slightly larger percentages were involved. These early experiences may have a causal relationship with the sex offenses many years later, but we lack proof of this.

As with all homosexual offenders, the childhood of the homosexual offender vs. minors was marred by poor health; the proportion reporting good childhood health is neither especially high nor low; a relatively large percentage described their early years as having been ones of poor health. Thus they are third from the bottom in a rank-order of prepubertal health.

Fifty-seven per cent of them masturbated before reaching puberty; this is the largest percentage manifested by any group, though a high incidence characterizes all homosexual offenders. In addition, again like other homosexual offenders, they tended to begin at an early age: slightly over half of those who masturbated before puberty began before age ten. Having the greatest incidence of prepubertal sex play and also the greatest incidence of prepubertal masturbation, the homosexual offenders vs. minors were, in preadolescence, the most sexually active group of all. This hypersexuality is a trait of all homosexual offenders. One is tempted to speculate that the strong sex drive (as indicated in the incidence of masturbation), which develops before society has made provision for heterosexual activity, may result in homosexual experiences. We do know that about one third of the boys learned of masturbation through early homosexual experience.

*183\161\2*

Compared with other groups, they had low coital frequencies before marriage. For example, even if we take into account only those who had premarital coitus, the average rate between twenty-one and twenty-five was once in three weeks—the second lowest frequency recorded. Mean frequencies are also quite low, always substantially less than those of the control group.

There is nothing especially interesting in the figures on their coitus with prostitutes; they tend to occupy middle positions in all the rank-orders. Prostitution increases in importance with age: in age-period 16-20 they had coitus with prostitutes about half as often as with companions, but in age-period 21-25 the frequencies are essentially equal. In the median frequency of premarital coitus with prostitutes at ages sixteen to twenty the incest offenders vs. minors rank second. However, the frequencies in this particular rank-order are so low—a matter of 3 to 11 times per year—that rank-order position is less meaningful.

While they had coitus with an average number of prostitutes before marriage (12), they had few nonprostitute coital partners—the average being five, the third smallest number recorded. This situation is in keeping with their below-average record of premarital petting.

The proportion of total sexual outlet derived from premarital coitus with companions is moderate in comparison to other groups, ranging from 12 to 30 per cent. However, the proportions derived from premarital coitus with prostitutes are quite large in age-periods 16-20 and 21-25, when these offenders rank third and first.

Like the incest offenders vs. children, a moderate number (56 per cent) claimed that lack of opportunity was a prime factor in their not having had, or having had more, premarital coitus. True, they got off to a rather late start in heterosexual activity and did not have large numbers of petting or coital partners, but any group in which nine out of every ten members had coital experience by age twenty cannot be regarded as having suffered deprivation. With regard to other restraints on premarital coitus—moral considerations, fear of pregnancy, disease, or public opinion—the incest offenders vs. minors seem about average. Relatively few (22 per cent) reported lack of interest as a major factor, but a somewhat large proportion (18 per cent, third in rank-order) were held back with their fianc?es by a desire for virgin brides.

Before closing the subject of premarital coitus, it is worth mention that these offenders more than any other group enjoyed their first coitus: 81 per cent (the largest proportion recorded) reported it as extremely enjoyable, while only 11 per cent (the smallest proportion on record) stated that it was unpleasant to mildly pleasant.

*141\161\2*

While there is nothing striking about their use of alcohol or their gambling habits, their drug use is quite unusual. These men had the third largest number (about 4 per cent) of opiate addicts, by far the largest number of habitual marijuana smokers (15 per cent), and were again by far the largest users of other drugs—chiefly the amphetamines and barbiturates. All in all, they rank second (37 per cent) in the use of any type of drug.

All this suggests a search for novelty and stimulus, a quest for “kicks,” that is quite typical of young impulsive delinquents. The relatively high percentages of opiate addicts and habitual marijuana users are by-products of too often repeated experimentation.

*99\161\2*

The majority of offenders were not married at the time of the offense: 44 per cent had never married and 28 per cent were separated, divorced, or widowed. We have, therefore, almost three quarters of these offenders as maritally unfettered males on the lookout (as are most unmarried males) for sex.

For roughly four fifths of them this was their first sex offense: a ratio in keeping with the concept of these offenders as “ordinary men” who were careless in the matter of age. This same idea is reinforced by the data concerning psychosis and neurosis: 2 per cent had a history of mental or emotional illness.

When the word “careless” was used in the foregoing paragraph, we did not mean to imply that the offense behavior was opportunistic. Actually 88 per cent of the offenses involved clearly premeditated behavior, and drunkenness was a quite minor element. Premeditation, however, does not necessarily indicate preference for immature females. The distribution of the ages of the females involved (grading from 15 per cent aged twelve to 40 per cent aged fifteen) shows the desire for more physically mature partners. One will recall that a relatively large number (17 per cent, the third largest percentage in this regard) of these offenders vs. minors stated that they preferred as sexual partners females aged sixteen or seventeen, while fewer desired females twelve to fifteen years old.

About three fifths of the girls were friends of the offenders, another fifth were strangers, and the remainder were acquaintances and relatives. The offenders can scarcely be accused of “victimizing” underage “pickups.” On the other hand, neither can the average offender claim ignorance of the girl’s age. The familiarity of the girl with the offender is reflected in her behavior: in the 110 cases where we have both the official version and the offender’s version of the offense, both agree that in 99 instances the girl did not discourage the sexual activity. This understatement conceals the fact that an undetermined number of girls actively encouraged it.

The locale of the offense was a residence in half the cases and an automobile in almost one quarter. This latter figure is high and probably is the result of the inconvenient youthfulness of the girl—she is too young to have a room or apartment of her own, and too conspicuously young for the man to feel comfortable about escorting her past the eyes of desk clerks, landladies, and neighbors. The auto is a solution to this problem, as most teenagers know.

Approximately two thirds of the cases involved coitus, and the remaining third involved either “heavy” petting or “necking,” the distinction between the two being whether or not there was genital stimulation. Obviously some of these would have progressed to coitus had the relationship been uninterrupted. The high percentage of coital activity is not so unexpected when one notes that while the girls ranged in age from twelve to fifteen inclusive, the average (median) girl was 14.6 years old.

In 15 per cent of the cases there was more than one male involved; this is a high percentage exceeded only by the aggressors vs. minors. At first one wonders why females aged twelve to fifteen should be particularly subject to such polyandrous attention, but a simple explanation exists: when society learns that a young girl has had some sort of sexual relationship with an adult male, not only that male, but any other adult male who was within a radius of one hundred feet is apt to be convicted. If there were copartners in the offense, there was usually one, less often two, and only rarely more. The traditional “line-up” or “gang bang” is essentially absent in the offenders vs. minors, but there does seem to have been a considerable amount of double-dating and of pairs of males hunting for girls.

As one would expect in a voluntary relationship, the risk assumed by the male centers chiefly on the ability of the girl to keep the relationship secret. We estimate that in 82 per cent of the cases there was no other form of risk. In only 4 per cent of the cases were there other factors that made getting caught a probability rather than a possibility. In brief, the offenders vs. minors took definitely less risk than did the offenders vs. children.

Who reported the sexual behavior to the authorities? The girl herself rarely did so directly. Usually the situation was discovered by friends or relatives who thereupon reported it. The suspicious mother and the garrulous girl friend are common sources of the offender’s downfall. An additional number of the cases came to light as a by-product of police investigation of other matters.

Slightly over three quarters admitted the sexual relationship to us without equivocation; 9 per cent made a qualified admission; and 13 per cent denied the behavior. These figures are close to those obtained by the authorities whose denial percentage was slightly higher. Since the ages of the females involved were closer to the age at which society considers a female a permissible sexual object, these offenders vs. minors could admit their behavior, not only to others but to themselves, far more easily than could the offenders vs. children.

*57\161\2*

1. Indiana State Farm, a state jail principally for misdemeanants with sentences ranging from 30 days to one year. The inmates were chiefly from the Midwest, including Kentucky and Tennessee, and strongly rural.

California prisons. These were the California State Prison, San Quentin; California State Prison at Folsom; California State Prison at Soledad; California Institution for Men, Chino; and the California Medical Facility, which at the time of our interviewing was at Terminal Island, but now is at Vacaville. With a few exceptions, all the inmates in these institutions were serving sentences for felonies; misdemeanants were excluded. Nearly two fifths of the prison group and almost one third of the sex offenders were in one or another of the California prisons. Since our society is highly mobile and since California has received an influx of persons from other regions, the inmates had been born and reared in many different states. In brief, the sample does not contain an undue number of California natives. In any case our studies have led us to believe that geographic location has relatively little to do with sexual attitudes and behavior; more important are considerations such as socioeconomic level and religious devout-ness. Consequently, we feel that our sample derived from California institutions would not prove markedly different from a sample drawn from institutions randomly selected. Indeed, many of the California inmates had served sentences in other states.

California Department of Mental Hygiene institutions. Sex offenders who have been adjudged sexual psychopaths, or who are under observation for judgment, are ordinarily confined not in prisons but in special institutions under the Department of Mental Hygiene. We interviewed men in the Metropolitan State Hospital, Norwalk (which no longer houses sexual psychopaths), and Atascadero State Hospital. Like the California prison inmates, many of these men were born and reared in states other than California.

Describing the sources from which the members of the control group were drawn is a difficult task, for in large part they are the result of ex post facto selection rather than of expeditions aimed at obtaining control-group case histories. For expository purposes one can consider them as coming from three types of sources:

1. The first was comprised of groups, organizations, and definable aggregates of persons—for example, church members, unions, parents and teachers associated with a nursery school, students of a particular high school, Salvation Army members and beneficiaries, etc. In some of the organizations a large number of the members had the requisites for inclusion in the control group; in others merely a few were eligible. All in all, 250 of the control-group males came from these sources. The number is smaller than one might have anticipated, since we excluded all individuals who came from sources known to be biased in favor of some particular sexual behavior. Thus, for instance, since we know that the incidence of homosexuality is unusually high in the world of the arts, we ruled out of our sample whole casts of plays and members of other organized art groups. This selectivity, it should be noted, is aimed at sources of histories, not at professions or individuals; an actor or painter who came to us as a member of a church or PTA would be incorporated in our control group. Similarly, we excluded what one might call “therapy groups”—persons with psychological problems which led them to clinics, psychiatrists, psychologists, and sometimes to us. Lastly, we excluded unusual groups, groups which we had sampled because of their atypical sexual traits; an example would be a group of transvestites.

2. The next type of source might be termed our “hospital sample,” and it was gathered expressly to enlarge and improve the control group. For this purpose we needed people with less than college education, preferably with less than tenth-grade education, many of whom should be unskilled or semiskilled workers. Such persons are the most difficult to obtain. Our usual mode of operation, addressing the assembled members of some group and then asking them for cooperation, was impractical here since the majority belonged to no organized groups, except for unions and churches whose meetings they did not necessarily attend with any regularity. Moreover, it is not easy to make use of either churches or unions—the very fact that we are allowed time at a scheduled meeting is in the eyes of many tantamount to official sponsorship of our efforts. This engenders various objections and resentments among some of the members who feel that they are being placed under unfair compulsion or at least being subjected to unwanted solicitation. Similar objections arise if one attempts to sample a factory or store via the employer, but tin’s difficulty is rarely encountered since few employers can afford to let us intrude “on company time.” On the other hand, to seek out individually the persons we wanted, explain our research to each, and gain their cooperation, is prohibitively costly in terms of money and time. To solve the problem, at least partially, we devised our “hospital sample.” With the cooperation of a number of hospitals in Baltimore, New York, and Buffalo, we examined the records of male patients in public hospitals and were able to sort out those whose education and occupations made them eligible for our control group. We then examined their medical histories and ruled out any chronic invalids or anyone whose physical condition could have had a long-term adverse influence on his sexual behavior. In brief, what we wanted was the man who had had reasonable health until the last year or two (which we would omit in our calculations), or, better yet, healthy men who entered the hospital because of some industrial or traffic accident. In all, we obtained 120 men from these hospitals. We found that such hospital sampling is unfortunately no final answer to our problem of obtaining case histories from the unskilled and semiskilled workers. The wide availability of medical insurance and various company and union insurance plans has resulted in the great majority of hospital patients having private physicians whose consent must be obtained before the patient can be solicited. Tracking down these busy doctors and trying to explain our research and its needs over the telephone has proven not feasible, nor is lying in wait to seize the doctor when he visits his patient or patients at the hospital. Consequently, we had available only those patients who had no private physicians and who were wholly under the jurisdiction of the hospital. These men are relatively few nowadays and tend to be both aged and indigent. There are, however, some specialized hospitals where the staff has essentially complete authority regarding treatment regardless of whether the patient entered via a physician or not. Such hospitals can be of great value to us, and through the cooperation of one we obtained 78 of our total of 120 hospital-derived cases.

3. The last type of source must be labeled simply as stray individuals whose histories were obtained fortuitously. Some of them came to us as by-products of our group sampling—for instance, a relative of a person whom we had interviewed as a group member. Others came in contact with us in a variety of ways: a visitor to the Institute, a janitor in a building where we were temporarily stationed, a hitchhiker, a seat mate on a train or airplane, a friend of a friend, etc. The case histories of these people were also carefully examined for selective bias, and a considerable number were rejected. For example, anyone who came to us avowedly or covertly because of some sexual problem or unusual behavior was not included in the control group. There are 107 stray individuals who passed this screening in our control group.

These three sorts of sources were compared on a number of items of demography and sexual behavior. Since the “hospital sample” was designed to obtain certain varieties of individuals whom we did not have in sufficient numbers in the pre-existing control group, it is obvious that the comparison showed some anticipated differences: the men in the “hospital sample” were much older, fewer had never married, and their occupational status was lower. In terms of sexual behavior there proved to be only one important difference: the “hospital sample” had a markedly lower incidence of homosexual activity than can be accounted for by differences in age or marital status. The discrepancy is especially noticeable in youth, but at present we cannot explain it.

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