Acute Bacterial Prostatitis hits suddenly, with the impact of a freight train, and it’s impossible to ignore. Its symptoms include: Chills and fever; blood in the urine; pain in the lower back and perineum (area between the scrotum and rectum); extreme pain, burning, urgency or difficulty urinating, which can lead to urinary retention; and usually an accompanying urinary tract infection. Symptoms of such intensity are frightening, and often they mandate an urgent visit to the doctor’s office or emergency room. Sometimes men need to be hospitalized for a few days. (It’s important to note here that this is no time for stoicism; men who have these symptoms need to seek medical help immediately.) The good news is that this condition is the easiest to treat; often it responds dramatically to antimicrobial drugs, and often it never returns.

If the condition does not begin to respond to treatment within a few days, something else might be involved—namely, a prostatic abscess. This is a localized accumulation of pus—like a pimple—under pressure in the prostate. If this is suspected, your doctor should order further tests, such as a prostate ultrasound or MRI, to find out for sure. And if an abscess is present, it can be drained, via a needle passed into the prostate from the rectum or perineum, or it can be removed by a procedure commonly used to treat BPH, called transurethral resection of the prostate.

*302\201\8*

In terms of anesthesia, recovery, and mode of access to the prostate, this procedure is similar to the TUR: An instrument called a resectoscope lights the way for surgeons to see the prostate; the resectoscope is threaded through the urethra, so no skin incision is needed. The difference is that, instead of removing the excess prostate tissue, surgeons just make two tiny longitudinal cuts in it. (See figure io.i.) These incisions extend from the bladder neck down into the prostate, and they break the ring of tissue’s stranglehold on the urethra— giving it “breathing room.” Like the TUR, this procedure is preferable for men whose prostates are not grossly enlarged, and is the procedure of choice for men in whom the prostate is smaller than thirty grams, or one ounce.

It is also better suited to younger men, mainly because of one key advantage: The TUIP is more likely to preserve normal ejaculation than TUR. (This has nothing to do with sexual function or performance; it means simply that these men are more likely able to father a child. Otherwise, there’s no noticeable difference in orgasm between the two procedures.) Men who undergo TUR report a slighdy better urinary flow rate than men getting the TUIP procedure. And it’s not certain whether the effects of TUIP last as long as those of TUR The re-operation rate is about the same for both procedures, about i to 2 percent a year.

One concern with TUIP is that it produces no resected tissue chips—and thus, no way of checking for prostate cancer; some doctors recommend going ahead and performing a biopsy of the prostate during this procedure, as long as they’re “in the neighborhood.” The average hospital stay for TUIP is one to three days.

*262\201\8*

In BPH as in real estate, location of growth makes all the difference—the size of the prostate may have nothing to do with the degree of obstruction. For example, in lateral lobe enlargement, the tissue compresses the urethra from the sides. However, these lateral lobes can become quite large without producing much obstruction—during urination, they just swing open and shut like double doors in a saloon. In middle lobe enlargement, which is sometimes described as a “cork in a bottle,” the tissue acts as a moveable plug that can flip to block the bladder neck and cause major symptoms of urinary obstruction— even though the prostate may actually feel small from the outside.

Because these symptoms are the most urgent, men with middle lobe enlargement are much more likely to seek medical relief for BPH than, say, men with simple lateral lobe enlargement. What’s more common? Evidence from studies suggests that about 50 percent of men with BPH have middle lobe enlargement, 20 percent have growth in the lateral lobes, and 30 percent have both lateral and middle lobe enlargement.

*225\201\8*

What should you do now?

Every man, at every stage of prostate cancer, needs a course of action, a plan for the future. And right now, more than anything, you need answers.

Your doctor may draw up an immediate plan of attack: Radiation therapy, hormone therapy, chemotherapy, or even all of the above. Many well-meaning doctors suggest one or more of these options because they want to do something—anything—right away, to hold off the cancer for as long as possible.

But let’s wait a minute. Now, before you embrace any of these approaches, is the time for us to examine some hard facts together:

The first fact is that once prostate cancer has established itself in the lymph nodes, it has almost certainly set up shop at other sites as well, most commonly in bone. The second is that to cure the disease—to get rid of all the cancer—it would be necessary to find and eliminate cancer cells at all of these sites throughout the body.

*186\201\8*

Prostatitis. In one study of 115 patients who had radioactive iodine seeds implanted, five men developed prostatitis (for a discussion of prostatitis, and reported severe irritative urinary symptoms. “Three of these patients were essentially ‘prostate cripples,’ who were truly disabled by their frequent and painful voiding,” wrote two of the investigators. Symptoms in the other two men got better after a TUR procedure (in which many of the radioactive seeds were removed) and long-term regimens of antibiotics. The investigators suspect that in these men, the seeds had become infected.

Urinary Problems. From 10 percent to 37 percent of men in several studies had urinary problems—including urethral stricture, bladder neck contracture, and damage to the urethra—that caused irritative urinary symptoms. Most of these occurred in men who had already experienced such problems (from BPH, for example) or who had undergone a TUR procedure. For example, incontinence, which occurred in 5 percent of men, was not a problem for men who had not had the TUR procedure. Another factor in the development of urinary problems seems to be placement of the seeds—trouble seems much more likely to develop when seeds are planted too close to the urethra. Some doctors are now hoping to avoid this problem by leaving a larger cushion of seed-free tissue around the urethra. However, in sparing the urethra, will they also be sparing some cancer? This is not certain.

Sexual Problems. These can include impotence, ejaculatory pain, pain in the testicles, and blood in the semen. The incidence of impotence seems to have a lot to do with a man’s potency before the procedure. One study, for example, found that only 7 percent of men reported impotence. In other studies, impotence is much more common. Note: In men who have radioactive seeds implanted, a man’s ability to have an erection appears to diminish over time, just as it does in men who get external-beam radiation treatment.

*148\201\8*

In terms of the percentage of these male sexual partners who were “pickups,” i.e., unknown prior to the sexual activity, the homosexual offenders vs. minors with extensive homosexuality were essentially like the equivalent homosexual offenders vs. children. One third estimated that over 80 per cent of their partners were “pickups,” a figure which, while substantial, is less than that of the prison group, the homosexual offenders vs. adults, and the control group.

Concerning who took the initiative in inaugurating homosexual activity, the homosexual offenders vs. minors are again like the homosexual offenders vs. children in showing a decided tendency to take the initiative. Some 70 per cent took the initiative more often than not, only 15 per cent the reverse, and the same proportion said the overtures were mutually balanced. Of course it is usually necessary for the adult to take the initiative where children and young teen-age males are concerned. To put it bluntly, the thirteen- or fourteen-year-old usually does not (unless he is a prostitute) proposition a male in his twenties or older.

This same matter of age preference seems, with one exception, to have reduced the commercial homosexual behavior of the homosexual offenders vs. minors. Relatively few (15 per cent) had been or were prostitutes, and a fairly large number (37 per cent) had never received

or given money in connection with homosexual activity. The one exception mentioned above consists of the 29 per cent (the largest proportion of any of the groups compared) who had paid, but had never been paid, for homosexual acts. This emphasis on payment is again tied in with disparity in age. Just as in the heterosexual groups, the old must frequently supplement their attractions with cash in order to obtain sexual relationships with the young. While the homosexual offender vs. children could “buy” his partners’ favors with tickets to the movies or with candy, the homosexual offender vs. minors preferred partners who were too worldly to be fobbed off with such childish bait; they wanted money. At this point we must make it clear that such payment was not necessarily regarded by either party as unabashed prostitution. In many instances the financial transaction was disguised as a gift or loan, even though both males recognized that niggardliness on the adult’s part could well jeopardize any future sexual relations. The situation is analogous to that, say, of the fifty-year-old businessman and the twenty-year-old showgirl; both would honestly resent an insinuation of prostitution, but both know that money is an integral part of the relationship.

Three quarters (the second largest proportion displayed by any group) of the homosexual offenders vs. minors with extensive homosexual histories reported having loved one or more males. Slightly over half (again the second largest proportion) had loved more than one male. This finding by itself would suffice to demonstrate the strength of the psychological orientation of these offenders. It would be unfair to depict them as aging “aunties” preying upon the immature; in many instances a real and deep relationship existed. One not infrequent tragedy is that the love was not mutual: the adult was deeply involved emotionally and dreaded the inevitable dissolution of the affair, while the teenager with the unthinking callousness of youth merely regarded him as a “nice guy,” but not as any vita] part of his life.

Like the homosexual offenders vs. children, few (27 per cent) of the homosexual offenders vs. minors with extensive homosexual histories displayed any identifying mannerisms. Such habits of dress or behavior seem primarily associated with homosexuality between adults, most are conscious affectations, others have through habit become involuntary, but all are culturally determined.

Of the groups containing a number of persons with extensive homosexual histories sufficient for statistical treatment—the three homosexual-offender groups, the prison group, and possibly the control group—the homosexual offenders vs. minors suffered the most regret over their homosexuality. Seventeen per cent were not greatly concerned, but nearly half expressed much regret. The amount of regret in their case is not far from that expressed by the homosexual offenders vs. children, but definitely exceeds that of the homosexual offenders vs. adults and far exceeds that reported by the prison and control groups. Such regret usually is not a moralistic guilt reaction, but a realistic appreciation of the social, legal, and emotional difficulites that beset the adult who is interested sexually in either boys or girls.

*192\161\2*

Nevertheless, nearly half of the incest offenders vs. minors can be put into one of three categories, each constituting around one fifth of the cases. First is the drunken variety, requiring no comment. Second are the subculture offenders of whom there were so many among the offenders vs. minors. These men regard any postpubertal female as a suitable sexual object and do not regard a stepdaughter as taboo since she is not a “blood relative.” Although geography was not used as a criterion in categorizing, we subsequently found that of the eight men classed as subculture offenders, six had lived their formative years as children and young adults in Arkansas and/or Oklahoma and the remaining two cases could well have been influenced by what one may call the Ozark attitude toward kinship, since one man had been born and reared in the vicinity of Joplin, Missouri, and the other had spent his life in rural areas of Indiana, Illinois, and Missouri. Third is the situational variety, where the initial incestuous act seems to have arisen from a concatenation of factors, each of which, if taken separately, may be regarded as within the normal range of attitude and behavior. The following case illustrates this. A young man who had been forced into marriage because of a pregnancy for which he doubted his responsibility was divorced from his wife before the birth of a daughter. Years later, when he had remarried, this daughter, then about fourteen, came to live with him following her mother’s death. The man regarded her almost as a stranger, not having seen her for some years, but accepted the responsibility. The girl was quite free and casual about her dress—her stepmother found it necessary to reprimand her—and the man was occasionally aroused by the sight. The marriage had been deteriorating before his daughter came to live with them and continued to do so; finally the wife left.

The man now found himself even more sexually stimulated by his daughter’s careless dress and affectionate behavior and his desires were enhanced by the knowledge that she was having coitus with boy friends. Their affectionate behavior took on a sexual tone, by degrees became outright petting, and within three weeks after the wife’s departure they had their first coitus. Thereafter they continued to have coitus several times a week. The man felt guilty about it, but this only served to reinforce the incest, for his guilt led him to drink and the drink so lowered his inhibitions that he sought coitus even more frequently. Eventually his daughter became pregnant; his estranged wife found out about it and told the police.

Less frequent varieties of incest offenders vs. minors include pedophiles, amoral delinquents, and those so emotionally disturbed as to fall in our category of psychotics.

While the dependent variety of incest offender was very common among the incest offenders vs. children, it is only sparsely represented among the incest offenders vs. minors. Perhaps if more of the unclassified individuals could be classified, we would find there were more of them.

A few senile deteriorates and mental defectives account for the remaining classified cases.

*150\161\2*

In age-specific incidence they also tend to reveal large proportions of individuals having premarital coitus with companions in the various age-periods. They rank fourth (50 per cent) at puberty-15; fifth (84 per cent) at 16-20; second (87 per cent) at 21-25; and fourth again (81 percent) at26^30.

Nearly four fifths had had coitus with prostitutes at some point in their lives, mainly before marriage. A study of the accumulative incidence clearly indicates that this percentage would be substantially higher were it not for the fact that the sample includes many young individuals. Actually, in terms of accumulative incidence, the aggressors vs. adults are one of the most experienced groups: by age sixteen, 21 per cent had paid for coitus (third in rank-order); by eighteen, 54 per cent (second); by twenty, 68 per cent (second); and by twenty-six, 84 per cent (first in rank-order). This history closely parallels that of the aggressors vs. children who always occupy first or second rank. The age-specific incidence figures emphasize the unusual amount of such activity among these aggressors: they rank from first to third in all age-periods from puberty to thirty-five. The proportion of men involved in premarital coitus with prostitutes in any five-year age-period increases from 14 per cent before age sixteen to a phenomenal 90 per cent in age-period 31—35. They are outstripped only by the aggressors vs. children. Thanks partially to the fact that many of them began coitus at an early age, a moderate 23 per cent had their first coitus with a prostitute.

Up to age twenty-five the aggressors vs. adults rank moderately high in frequency of premarital coitus with companions, the frequencies being below those of the prison group and the heterosexual offenders vs. minors, and markedly less than those of offenders vs. adults. The average (median) aggressor vs. adults had premarital coitus 30 to 40 times a year from puberty until he was twenty-five; the equivalent frequencies for the control group are 12 to 20 times a year.

The frequency of premarital coitus with prostitutes was neither high nor low. Before marriage, the average aggressor vs. adults had 14 coital companions, the fifth largest number. The number of premarital partners who were prostitutes is again moderate—11.

As a result of the rather high frequencies mentioned earlier, these aggressors derived fairly large proportions of their total sexual outlet from premarital coitus with companions; they are nearly always in the upper half of any rank-order. The proportion of total outlet so derived begins at 23 per cent in the early teens and increases to 41 per cent by age-period 31—35. The proportion of total outlet from premarital coitus with prostitutes is moderate, never exceeding 17 per cent.

A study of the factors they reported as having substantially impeded their premarital coitus shows that they are similar to the aggressors vs. minors in a lack of moral considerations, as well as in indifference to pregnancy and venereal disease. Fifty-nine per cent, the fourth highest percentage, claimed that they had lacked opportunity for more premarital coitus. A moderate proportion (33 per cent) stated that they did not have more premarital coitus because they were not interested in more. Nine per cent, again a moderate number, were restrained by fear of the opinion of others if they were found out. Whereas the aggressors vs. minors were singularly indifferent about whether their brides were virgins or not, the aggressors vs. adults were more inclined to have definite opinions. Ten per cent, a somewhat small number, strongly desired virgins; 47 per cent were wholly indifferent; but 13 per cent, the largest percentage recorded, wanted experienced brides.

*108\161\2*

Like the offenders vs. minors, they were moderately monogamous: two thirds of those who married did so but once, relatively few (21 per cent) twice, and a moderate number (12 per cent) three times or more. In the number of brief marriages ending in separation or divorce the offenders vs. adults are not distinctive.

While the offender vs. children hastened into marriage on short notice and the offender vs. minors was inclined prudently or fearfully to delay, the offender vs. adults occupies an intermediate position in a rank-order of how long an acquaintance he had with his future wife before marriage.

Interestingly enough, while these men were extremely active in coitus before marriage, only half had premarital coitus with the females who became their first wives; this is a relatively low percentage. One will recall that nearly one fifth of them expressed a strong desire for a virgin wife. They had no scruples about premarital coitus with anyone other than the girl they hoped to marry—they epitomize the double standard. There is nothing distinctive in the picture of prenuptial pregnancy—an average number of the women they married were pregnant at the time.

For every 100 married offenders vs. adults 186 children were born. This is a moderate number compared to other groups, but in view of the age of the husbands (the average husband being not quite thirty-two ) shows a somewhat above-average fertility.

Like the offenders vs. children, the offenders vs. adults tend to spend little time in foreplay prior to marital coitus—ranking sixth, with 36 per cent, in the list of those whose foreplay averaged three minutes or less. The heterosexual offenders vs. children are fourth, and the offenders vs. minors are seventh. A moderate proportion (20 per cent) devoted half an hour or more to the coital prelude, and 44 per cent (again a moderate number) fell between the two extremes.

Again like the offenders vs. minors, very few of the offenders vs. adults had had mouth-genital contact with their wives. Some 85 per cent, the second largest proportion recorded, never had this experience. Very few had either cunnilingus or fellation only, and but 10 per cent

(the second lowest figure recorded) had engaged in both types of activity in marriage.

Curiously enough, this conservatism is not mirrored in other sexual techniques: a moderate number had had anal coitus with their wives, and the number who had tried coital positions other than the usual female-supine male-prone is not particularly low.

In premarital life the offenders vs. adults were the undisputed Don Juans of our study, but marriage seems to have reduced them to a sexual mediocrity. The rates of marital coitus for the average individual varied from low-intermediate earlier in life (in terms of rank-order) to intermediate later in life. This upward trend later in life is seen more dramatically in the mean frequencies: here the offenders vs. adults hold intermediate positions up to age thirty-five and then leap to first place in age-period 36-40. This eleventh-hour marital renaissance is the work of a few individuals—the average (median) offender vs. adults is in an intermediate position in age-periods 36-40 and 41-45, with coital frequencies of 1.7 to 1.5 per week.

The proportions of total sexual outlet afforded by marital coitus do not increase or decrease with the frequencies described above. Instead, they are moderate in early life, gradually increasing to 89 per cent between thirty-one and thirty-five, which wins these offenders first place in the rank-order. They maintained essentially this figure (and third rank) in the following age-period, and then suddenly dropped— both relatively and absolutely—between forty-one and forty-five, when only 78 per cent of their total orgasms were in coitus with their wives. Much of this dramatic drop is due to the fact that the sample at this age is small and one individual in it began to have frequent extramarital coitus.

The orgasm frequencies of their wives as reported by the offenders vs. adults are not unusual.

In an over-all evaluation of their marriages, more of the offenders vs. adults than almost any other group (19 per cent, third largest proportion) reported their marriages as very unhappy. A moderate number said they were very happy, another moderate number said “rather unhappy,” and relatively few said they were moderately happy. In terms of absolute numbers the happy marriages far outweighed the unhappy. One may summarize by saying that the marital happiness of the offenders vs. adults was not importantly less than that of most offenders, but much less than that of the control-group individuals.

*66\161\2*

In formulating this category of sex offenders we encountered the problem of eliminating from it the cases that involved the use of physical force or direct threat. Force ranges from unmitigated violence to, let us say, holding a child by the wrist; threat runs the gamut from specific verbal threat or brandishing a weapon to a subtle implication. In any relationship between a child and an adult there is always in the background an element of duress; the inevitable disparity in strength and social status is an omnipresent factor. A man, even though a stranger, is in an authoritarian superior position. While it was manifestly impossible to cope with these vaguer (but nonetheless effective) forms of force and threat, we were able to exclude from heterosexual offenders vs. children anyone who told us of using force or threat or whose official record mentioned its use.

This does not mean that the children involved were necessarily eager and cooperative; it does, however, mean that the man did not have to resort to physical violence or specific threat in order to achieve the sexual relationship.

The horror with which our society views the adult who has sexual contact with young children is lessened when one examines the behavior of other mammals. Sexual activity between adult and immature animals is common and appears to be biologically normal; however, it reflects no preference for the immature as such.

Among some preliterate societies a sexual relationship between an adult and a child evokes only a mildly negative reaction. The relation ship may be considered somewhat ludicrous or it may be considered evidence that the adult is too socially inept or unattractive to obtain an adult partner. Fear of ridicule and loss of prestige operate even in sexually permissive cultures to restrict sexual activity between children and adults. In a small number of societies infants or occasionally children may be masturbated by adults (usually relatives) in order to soothe them, but there is no evidence that the adult receives any sexual gratification. In some cases such masturbation seems to be done as a casual jest or as an amusing display of the child’s sexual potential.

The universal tendency to express affection and love through physical contact naturally comes into conflict with taboos concerning incest, homosexuality, and age disparities. In our culture the dilemma is solved by assuming that physical contact is not sexually motivated in certain cases. For example, we see a sexual element when an unrelated male and female embrace, but when a mother and adult son embrace we automatically reject the idea of there being any sexuality involved. In the same way a certain amount of physical contact, which would be construed as sexual under other circumstances, is socially permitted between children and adults. If the child and adult are related, it is not only permitted but expected.

Humans, however, are not psychologically and physically so constituted that a particular act can always be invested with purely sexual or asexual overtones as the social situation may demand. Our physiology and our subconscious recognize and react to warmth, body contact, and other stimulation; they do not make the fine social differentiation between, say, one’s wife and one’s sister-in-law. Thus a grandfather bouncing his grandchild on his lap may be aghast to discover he is developing an erection; a brother embracing his sister upon his return from a long absence may guiltily recognize a sexual response in himself.

It is easy to envision how a person under stress and starved for affection might find in the uninhibited responses of a child a strong sexual stimulation. If his culturally constructed mental barriers against such behavior are, in addition, weakened by intoxication, senility, or emotional upset, it is not hard to see how an initially asexual relationship can readily become sexual. The actual sexual behavior may amount to little and be hastily ended, but the act is irredeemable-Uncle George or the nice young roomer upstairs or the old man who lives down the street or whoever he may be is now a sex offender both legally and in the eyes of his fellow men. On the other hand, of course, not all offenders vs. children are innocent victims of the conflict between biology and society; the nice young roomer may have had his eye on his landlady’s daughter for months.

*23\161\2*