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Shortly after we began interviewing sex offenders it was evident to us that some of them committed the same offense over and over again in what seemed a compulsive repetitious pattern of behavior. Feeling that these individuals are of particular concern to society, we have in this chapter labeled them “patterned” offenders and compared them to other sex offenders who do not exhibit this repetitious pattern of offense behavior. The latter we labeled “incidental” offenders.

The separation of offenders into the patterned or incidental categories is based either on the record of criminal conviction or on the individual’s admission to a history of offense behavior for which he was not convicted. For example, a man with two convictions for exhibition was categorized as a patterned exhibitionist, and so was the man who had but one conviction but told us he had repeatedly exposed himself to women. The individual labeled incidental was the man with only one offense of a given type and no indication of additional activity of that same type.

Obviously only a few types of sex offenses lent themselves to this patterned as against incidental dichotomy; for example, virtually 100 per cent of our offenders vs. adults would by definition be patterned offenders. In other instances, as in the aggressors vs. children, the sample was already too small for further division. Consequently, we made the patterned vs. incidental analysis on but six groups: the heterosexual offenders vs. children, the incest offenders vs. children, the homosexual offenders vs. children, the aggressors vs. adults, the peepers, and the exhibitionists.

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In general, it may be said that there are very few good studies of recidivism and that no study has examined the recidivism of a large sample of first offenders throughout their criminal careers. Most studies of offenders of any type have focused on what can be called “failure” populations. An extended analysis of the criminal records of a population that is currently institutionalized is the common technique. Thus, excluding the first offenders, all other persons are “failures” in terms of remaining outside institutions. The primary defect of these studies, and of ours also, is that there is not present (and cannot be) in the institutionalized population those first offenders who do not get convicted the second time, and those second offenders who do not get convicted the third time, and so on. What these studies do show is the profile of previous offenses committed by men currently in prison. The degree to which their criminal careers are similar to the careers of men who did not return the next time, whatever time that might have been, is at present moot.

Recidivism rates vary considerably for different types of offenders; this is partially a function of the offense and partially a function of the length of sentence. Certain types of offenders, primarily those with a traditional career of property offenses, serve relatively short sentences and have high rates of recidivism both when released on parole and on unconditional release. Part of this recidivism rate is due to years of exposure in the free community, but also part is due to an involvement in social groups with standards and values at variance with majority sentiments. The opposite picture, in terms of both exposure and criminal subculture involvement, is observed in the case of both homicide and sex offenders.7 Except for exhibitionists, peepers, and those convicted of statutory rape, most other sex offenders receive fairly long sentences, cutting down years of exposure. This is also practically inevitable in homicide cases. All the other offender groups show relatively low recidivism rates when parole-violation rates are computed, for in addition to the years spent in institutions away from objects of their offenses these sex offenders (as well as those noted above) are not supported by social groups or norms which perpetuate offense behavior.

Taking the total convictions, sexual and nonsexual in nature, it appears that half of the sex offenders have more convictions than the prison group and half have fewer. There were 3.5 convictions per capita for the prison group; at one extreme were the aggressors vs. children with 5.5 and at the other the incest offenders vs. adults with 2.4 convictions. We may equate number of convictions with recidivism despite the fact that in some cases what was one unit of behavior resulted in convictions on several charges.

In general, the aggressors are the most recidivistic group. In per capita convictions they rank first, fifth, and sixth (5.5 to 3.9 convictions). Of the four groups with the smallest proportions of first offenders, three are the aggressors with only 17, 11, and 8 per cent of the members having one conviction on their records. In the rank-order of those with seven or more convictions they rank first (28 per cent of the aggressors vs. children had seven or more, convictions), fourth, and fifth.

The second most recidivistic are those offenders who do not make physical contact: the peepers and the exhibitionists. In per capita convictions they are second and third (4.3 for the exhibitionists and 4.2 for the peepers). They again rank second and third in the proportion who had seven or more convictions, this being true for one fifth of the peepers and 16 per cent of the exhibitionists. The recidivism of these two groups is a product not only of their compulsivity but also of the tendency for the courts either to omit imprisonment or mete out short sentences for these nuisance offenses.

As a group the incest offenders are the least recidivistic, averaging 2.4 to 3.0 convictions per capita. Moreover, slightly more than two fifths of the incest offenders vs. minors and adults were first offenders, ranking first and second. In a rank-order of those with seven or more convictions the incest offenders occupy the lowest three positions, with only 2 to 4 per cent showing such extreme recidivism.

The heterosexual offenders also have few repeaters: compared to those in other groups many were first offenders (they rank fourth, fifth, and sixth) and the per capita numbers of convictions are also low (2.8 to 3.0). Except for the incest offenders, they had the fewest members with seven or more convictions.

Lastly, there is a definite correlation between recidivism and age of the sexual object. In all four of our tripartite groups the men whose offenses were against children have more per capita convictions than those (within the same tripartite group) whose objects were older. Similarly in a rank-order of first offenders those who offended against adults or minors include larger proportions of first offenders than those who offended against children or who used force against females of any age.

Thus far we have been speaking of recidivism in terms of crimes of all sorts, yet a study of sex-offense recidivism yields much the same picture. The exhibitionists and peepers again are the most recidivistic (3.1 and 2.5 sex offenses per capita, ranking first and second) and the aggressors come next, ranking fourth, fifth, and seventh with from 2.0 to 2.2 offenses. The incest offenders and heterosexual offenders once more are the least recidivistic of the tripartite groups, the incest offenders vs. adults again having the lowest rate: 1.2 sex offenses per capita.

If one looks at recidivism solely as repetition of the specific offense, rather than any sex offense, the picture becomes somewhat confused. The exhibitionists and peepers still monopolize the top ranks (2.1 and 1.6 specific sex offenses per capita), and the incest and heterosexual offenders vs. adults the bottom ranks (1.0 and 1.1), but all other offenders and aggressors are mixed in helter-skelter between these extremes. However, it is worth noting that ranking high in this specific sex-offense recidivism (third and fourth ranks) are the homosexual offenders vs. adults and minors: our two most homosexually oriented groups. Strong homosexual motivation and recidivism are, in our culture, necessarily linked. An incest offender can turn to unrelated females, an aggressor can learn to win cooperation, the pedophile can try to satisfy himself with older girls, but the homosexual offender is, in most states, trapped in a situation where his activity is apt to be punished regardless of the age, relationship, or cooperativeness of his male partner.

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The frequency of sexual intercourse in marriage varies greatly among the different groups. This fact produces some drastic changes in the rank-orders of coital frequencies during various age-periods. The median frequencies are, naturally, more stable than the mean frequencies, but even in the median frequencies there are some cases of sudden variation—as, for instance, the rise of the exhibitionists from last place at age-period 21-25 (with a coital frequency of 2 per week) to fourth place at age-period 26-30 (with a frequency of 2.5). While rank-order changes, ordinarily one does not find increases in actual frequency—the picture is generally one of inexorable decrease in frequency with increasing age, and the range in variation of frequency correspondingly narrows.

In terms of median frequency, it appears that the most active groups are the aggressors vs. adults, the offenders vs. children, and homosexual offenders vs. minors. Interestingly enough, the latter two groups had only a moderate amount of coitus before marriage, and the aggressors vs. adults never rose above third rank in this activity. Clearly, when marriage makes coitus more easily available the whole picture changes; it is evident that the premarital frequencies reflect savoir faire, appearance, social milieu, and other factors as much as or more than they reflect what one may term “sex drive” or strength of motivation. The control group begins in second rank in age-period 16-20 and exhibits thereafter a rather uniform and gradual decline in frequencies resulting in the group occupying intermediate status in the rank-orders.

There is considerable variation in which groups exhibit low frequencies, but the homosexual offenders vs. children are more uniformly low than other groups. It is interesting that the offenders vs. adults, who were the most active sexually before marriage, always rank low in frequency of coitus within marriage. The prison group and the offenders vs. minors, both of whom distinguished themselves with high frequencies before marriage, lapse into moderate to low frequencies thereafter.

Examination of the frequencies suggests that in the great majority of cases actual protracted coital deprivation cannot be a major factor in sex offenses committed by men currently married. One sees that while a minority of the sex-offender groups exceeds the control group in frequency of marital coitus, the others do not lag far behind, and between ages twenty-six to thirty-five the majority of sex-offender groups exceeds the prison group. Even in those age-periods wherein the control or prison groups rank high, their absolute frequencies are not greatly above those of the sex offenders.

Mean frequencies of marital coitus are extremely erratic. About all one can say is that the aggressors vs. adults and the homosexual offenders vs. minors tend to have higher frequencies, while the incest offenders vs. adults and the offenders vs. minors (after age thirty) have very low frequencies. All incest offenders are to be found in the lower halves of the rank-orders, and the exhibitionists are usually to be found with them.

In both means and medians the occasional high ranking of homosexual offenders is noteworthy. This seeming inconsistency led us to examine in detail the case histories of the ever-married homosexual offenders vs. adults. Some of these men were more heterosexual than homosexual in orientation, and their homosexuality did not reduce their frequencies of marital coitus. However, some men were definitely more homosexual than heterosexual and often had markedly underdeveloped premarital histories, yet these men married (generally briefly and but once) and began marital coitus with high frequencies. It is true that since marital coitus tends to be more frequent in early marriage than in late, the coital frequencies of brief marriages will exceed those of long-time marriages, but this explanation alone does not suffice. We presently cannot explain why some predominantly homosexual males have a brief but intense (in terms of frequency) unheralded outburst of heterosexuality generally in marriage. The best explanation that occurs to us is based upon the strength of “sex drive.” The homosexual offenders seem to have the greatest “sex drive”; note that their total sexual outlet always exceeds that of other groups. Given individuals with a strong “drive” and with various degrees of heterosexual inclination, put them in a situation where coitus is available (marriage), and one may expect occasional high coital frequencies.

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Whereas in many preliterate cultures the knowledge of coitus comes early and naturally, the acquisition of such knowledge is, in our culture, much more belated and more often traumatic. Belated though it may be, the great majority of our sample knew of coitus before reaching puberty. Taking thirteen as an arbitrary age approximating the onset of puberty, and studying the percentages of only those who learned of coitus at thirteen or older, we can see a few interesting facts emerge. Of our sexually most restrained group, the incest offenders vs. adults, a full 36 per cent learned of coitus at or after age thirteen; this is the greatest percentage recorded. The peepers, of whom also a substantial proportion are sexually inhibited, are in second place with 32 per cent, and the exhibitionists are third. Conversely, one of the most sexually active groups, the prison group, is next to last in rank-order with but 16 per cent who had not learned of coitus before thirteen. However, the inference is weakened by the fact that about one fourth of the heterosexual offenders vs. minors and adults, both also sexually active groups, were ignorant of coitus prior to age thirteen. This curious fact is probably the result of their reaching puberty relatively late;

22 per cent of the heterosexual offenders vs. minors did not reach puberty until age fifteen or later. Since an interest in sex is intensified at and near puberty, and since interest leads to acquiring knowledge, it is reasonable to suppose that deferred puberty correlates with belated knowledge. This is substantiated by the fact that the incest offenders vs. adults lead in delayed puberty, and, as pointed out above, 36 per cent learned of coitus at or after age thirteen.

All in all, the age at which a male gained his first knowledge of coitus does not correlate with the age at which he had his first coitus, and correlates with age at puberty only in extreme cases (i.e., late knowledge with very late puberty, early knowledge with very early puberty). Evidently numerous variables are involved in a complex fashion.

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While there is nothing unusual in the proportion of exhibitionists who experienced nocturnal emissions, they began rather late in life: the median individual had his first emission at age 16.9 years.

The unmarried exhibitionists show a relative increase in the number who had nocturnal emissions during the successive age-periods. Beginning with a somewhat small number (29 per cent) in age-period puberty—15, they climb to intermediate rank until age-period 36—40 when they actually exceed the control group and rank second with 63 per cent. The married, however, show no such trend; their age-specific incidence figures are ordinarily moderate except between twenty-one and twenty-five when they rank second with 58 per cent, just below the control group.

The frequencies of the unmarried exhibitionists tend to be rather high. This tendency is not clear in median frequencies until the fourth decade of life when they essentially match those of the control group, but in mean frequency calculations it becomes much sharper: the exhibitionists rank second or third between sixteen and thirty with frequencies of 17 to 29 a year.

The unmarried exhibitionists derived a relatively large proportion of their total outlet from nocturnal emissions, usually ranking third or fourth in this respect. Beginning in their early teens with 2.5 per cent they reach their maximum figure (14 per cent) in age-period 26-30.

The married exhibitionists have a somewhat different pattern: between the ages of sixteen and twenty, they found a very small proportion (1 per cent) of the total outlet constituted by such emissions, but later they achieved first or second rank with percentages as high as 7. Similarly the separated, divorced, or widowed increased from 2.6 per cent (in age-period 21-25) to 7.1 per cent (age-period 41-45). Only one other group shows this as yet inexplicable tendency for the proportion of total outlet derived from nocturnal emissions to increase with age regardless of marital status.

The exhibitionist is also apt to have exotic dreams: he ranks second in sadomasochistic dreams (although only two men were involved), third in dreams of animal contact, and first (11 per cent) in bizarre dreams. The high rank in bizarre dreams comes largely from dreams of exposing genitalia—the same theme that made the exhibitionist also rank first in bizarre masturbatory fantasy.

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incidence: common

cause: virus (Molluscum contagiosum)

symptoms: painless, dimpled bumps

treatment: topical treatments, but will resolve without treatment

WHAT IS IT?

Molluscum contagiosum (molluscum for short) is a skin infection caused by the virus Molluscum contagiosum, which is a member of the poxvirus family. It is usually a relatively benign infection that causes harmless skin lesions and does not become chronic. Molluscum is very common among children, who often have lesions on the face, trunk or extremities and who usually acquire the infection through nonsexual contact. Adults usually acquire the infection in the genital area through sexual contact.

Since most people do not seek treatment for molluscum and the infection is not reportable to health departments in the United States, it is difficult to estimate how common it is. It is a commonly seen skin problem in pediatric clinics and sexually transmitted disease clinics. It occurs throughout the United States and the world, but it is probably more common in warmer areas.

People who have compromised immune systems, such as those with acquired immunodeficiency syndrome (AIDS), often have extensive lesions on the face and other areas of the body. It is not clear whether the virus is latent on the skin and becomes active when the immune system weakens or whether persons with AIDS are more vulnerable to new infection.

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very common virus (herpes simplex virus), painful sores on the skin, with many variations, no cure; antivirals to treat and prevent symptoms

WHAT IS IT?

Herpes is a viral infection caused by the herpes simplex virus (HSV), of which there are two types: herpes simplex 1 (HSV-1) and herpes simplex 2 (HSV-2). Although HSV-1 and HSV-2 are distinctly different viruses, they cause similar symptoms. HSV-1 usually occurs around the mouth (where it causes cold sores), and HSV-2 usually occurs in the genital and anal areas. However, infection with these viruses can occur anywhere on the body. Mucosal skin surfaces—such as those around the mouth, genitals, and eyes—are most vulnerable, as are areas of broken skin.

The Greek word herpes means “to creep,” referring to the way in which the virus moves along nerves from the root bodies out to the surface of the skin. Genital herpes was first recognized as an STD in the 1700s, but the virus itself was not identified until the early 1960s. The herpes simplex viruses are only two of the viruses in the herpes virus family, which also includes the varicella-zoster virus, which causes chicken pox and shingles; the Epstein-Barr virus, which causes mononucleosis; and cytomegalovirus.

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For people with CMV infection that is symptom free, no treatment is necessary. For people with CMV symptoms, two medications, foscar-net and ganciclovir, have been effective in treating the disease (although the virus remains in the body, the symptoms are controlled). Both of these medications are given intravenously, and both have potential side effects. A new, oral form of ganciclovir is now available as well. In persons with AIDS who are being treated, these medications must often be taken continuously, since stopping them would allow the virus to become active again.

The medication that has been used to treat herpes simplex infections, acyclovir, has not been effective in the treatment of CMV.

Researchers are working to develop a vaccine to prevent the acquisition of CMV but so far no vaccine has effectively provided long-term protection.

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Picture someone ice-fishing—cutting a tiny, inconspicuous hole, dropping a line and bringing out a big fish. That’s the idea behind laparoscopic surgery. It’s much less invasive than traditional surgery that involves an incision, and the benefits to patients include shorter hospitalization, quicker recovery time, less postoperative pain, and a better cosmetic result—a few tiny holes, for example, instead of a scar several inches long.

There is a growing movement in surgery to be minimally invasive—to make smaller holes, not big incisions, and, whenever possible, to use the body’s natural passageways, such as the urethra, to reach internal organs. One doctor describes it as “surgery through telescopes.” (The concept itself is not new; use of the endoscope as a means of exploring the body dates back to the turn of this century.) This is the thinking behind the laparoscopic techniques to reach the pelvic lymph nodes in men with prostate cancer.

A man is diagnosed as having early-stage disease. Because there’s no evidence that the cancer has spread, he’s a candidate for curative therapy— surgery or radiation. But as we know, unfortunately, sometimes cancer has indeed spread, in tiny amounts, to the lymph nodes.

So: Is the cancer really localized? For many men who undergo radical prostatectomy (the retropubic procedure), this question is answered before surgery, for others, it’s answered on the operating table. Before even touching the prostate during a radical prostatectomy, the surgeon removes the patient’s pelvic lymph nodes and sends them to pathology, where sections of the nodes are frozen and examined for cancer. If widespread cancer is found, the surgeon doesn’t remove the prostate because it wouldn’t do any good. But the man still must spend several days in the hospital to recover from the incision.

For this and other reasons, an increasing number of men are undergoing laparoscopic pelvic lymphadenectomy (dissection of the lymph nodes) as a means of staging prostate cancer. It has minimal side effects, a brief hospital stay (one or two days), and men can go back to work in one to two weeks. Some men are even having this done as outpatients.

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As with breast cancer, there seems to be a close association between a family history of prostate cancer and a man’s risk of developing the disease. Big deal, you may be thinking: If prostate cancer is inevitable for so many men—if it’s so common—then what difference does it make if it runs in my family? Unfortunately, the prostate cancer that runs in families is much more likely to strike at a younger age, when a man might not even be looking for trouble or having yearly prostate exams.

Recently, scientists at Johns Hopkins showed the undeniable link between a family history of prostate cancer and a man’s probability of developing the disease (see table 2.1). This study showed that if your father or brother has prostate cancer, your risk is two times greater than the average American man’s

Table 2.1 Does Prostate Cancer Run in Tour Family?

Number of Affected

Relatives
Risk
Father and/or brothers

One
2-fold
Two
5-fold
Father/brother or

Grandfather/uncle

One
1.5-fold
Two
2.3-fold
Note: Your risk of developing prostate cancer starts at about 13 percent and goes up from there, depending on your number of affected relatives.

(which is about 13 percent). It goes up from there: Depending on the number of affected relatives you have and the age at which they develop the disease, your risk could be as high as 50 percent. Does your family history suggest hereditary prostate cancer (HPC) ? You fall into this category if you have three first-degree relatives (a father or brothers) who develop prostate cancer, or two first-degree relatives, if both developed it before age 55, or if prostate cancer has occurred in three generations in your family (grandfather, father, son). Note: HPC can be inherited, from either your father or your mother. For this reason, it’s important to find out from both your father and mother about a history of prostate cancer in their brothers and father. (If neither relative is living, ask other family members, or investigate family records.) Men in families with HPC have a 50 percent chance of developing prostate cancer and are more likely to develop it at a younger age than most men. In HPC families, men should have a digital rectal examination and PSA test every year, beginning at age 40.

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