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Are there no drawbacks to this program of complete equality? What will become of the children, for example, if women possess economic independence, which can be attained only by working outside of the home? And will there be any home at all? These questions are the stumbling blocks in the elevation of woman from the mere status of cook, housekeeper and nurse-girl to that of a fully developed human being who can be a real companion to her husband. The difficulties are not so serious, however, as conservative people would like to make them out to be. Beyond having to take several leaves of absence from outside work during pregnancy and lactation, there is no reason why a woman should have to neglect her career on account of children.Day nurseries and pre-schools, which can eventually be made part of the public school system, not only enable a mother to pursue her daily work outside the home but are much better for the child than the type of training or lack of training that it receives from most mothers. And the attention which both the father and mother can give to the children in the evening and over week ends will lend all the “personal touch” that is needed. As a matter of fact, with both parents working, with housekeeping done for the most part by specialists in that field, and with most meals eaten in family restaurants instead of laboriously prepared at home, both parents will actually have more time to devote to their children in a constructive way than at present. The improvement too in the relations of husband and wife, which will result from greater equality, will make home-life even more real and pleasant than it has been under the old regime, and both parents and children will be happier.Objection may be raised to woman’s entering industry because this will flood the labor market, reduce wages and throw deserving men out of work. While there may be, and in fact are, some difficulties of this sort, yet they may be regarded as merely transitional. Besides, the entrance of women into industry is quite gradual, and probably, if present tendencies continue, the population will sooner or later be sufficiently reduced to enable both men and women to have employment, with reduced hours and better pay, brought about by the continued improvement in industrial technology and in the greater power of workers to demand their due share of the products of industry. It is beyond the scope of this book, however, to enter into all the intricate economic questions that the proposed equality of the sexes raises. If the ideal is worth attaining, surely it can be made economically practicable.*106\275\8*

For years, doctors considered BPH to be a simple disease. The prostate was enlarged, it obstructed the bladder. The obstructing tissue was removed, and the patient got better. This simplistic approach to the disease was possible in an era when there was only one form of treatment for BPH—surgery.

However, as medical therapy has become a reality, it’s now clear that BPH is a complicated disease, involving hormones and other factors, appearing in various kinds of cells, taking many shapes, and affecting every man differentiy. In some men, BPH manifests itself mainly in glandular epithelial cells; under the microscope, their prostate tissue looks like a sponge. In other men, BPH tissue consists mainly of smooth-muscle and stromal cells, with very few glands. In some men, prostate enlargement presents itself in big lateral lobes; other men produce a middle lobe that can seal off the bladder neck like a cork in a botde. Finally, in addition to all these considerations, the response of the bladder is crucial: If the bladder’s in fairly good shape and is able to respond to the obstruction, a man is likely to respond well to any kind of drug treatment. But if the bladder muscle is stretched out and is no longer able to contract forcefully, it might be that no drug can improve urinary flow—no matter how well it relieves the obstruction.

In the not-too-distant past, when the only option was surgery, treatment was simple. By producing a “surgical strike,” and eliminating the critical tissue that was causing the obstruction, results were good—despite the causative factors, the makeup of tissue, type and degree of obstruction, configuration of the prostate, or even the bladder’s response. By removing the obstructing tissue, the bladder outiet was opened so wide that often even the weakest bladder was able to empty.

Contrast that with the current approaches to medical management of BPH: Treating patients with hormonal therapy to shrink the prostate can only be expected to work in cases when a hormonal factor plays a big role in the disease, and when the glandular tissue is primarily responsible for the obstruction.

Conversely, using smooth-muscle relaxants can only be expected to work well in men with mostly smooth-muscle tissue in their prostate, and a predominantly dynamic form of obstruction. Also, because drugs provide only modest relief of obstruction, neither approach can be expected to be very effective in men with a weak bladder muscle.

Why Diuretics Don’t Help

Diuretics work by altering the way the body metabolizes sodium; the kidneys absorb less water, so more of it leaves the body in the form of urine. For most people, diuretics mean more frequent urination and a more forceful stream. But they can be disastrous for a man with BPH. Imagine a clogged pipe. Turning on the faucet full-blast isn’t going to make the obstruction go away. Instead, the water’s just going to back up, or overflow (and, in the case of BPH, distend the bladder). The only way to get rid of the clog is to dissolve it with chemicals, or to extract it from the pipe.

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You’ll receive fluids intravenously (through your veins) the day of surgery, but you should be able to eat normal meals the next day. You’ll probably be given a stool softener or mild laxative to keep you from straining and to make the first bowel movement after surgery easier. A Foley catheter, inserted in the penis (and anchored by a tiny balloon in the bladder) during surgery, will remain in place until the bleeding has stopped. In addition to removing urine from your body, the catheter also keeps the bladder irrigated to help prevent infection or a blood clot from developing. Another catheter is inserted during surgery; this one is called a suprapubic tube because it’s placed directly in the bladder and exits through the lower abdomen. It will be taken out between three and five days after surgery. Your incision probably will have staples, not stitches, and these will be removed one week after the operation—probably on your return visit to the doctor’s office. When you get home, take it easy but don’t just sit around the house—gradually resume your usual exercise and activity. You should feel fully recovered within four to six weeks.

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Your doctor may want you to undergo further evaluation, which may include something called a “nocturnal penile tumescence test.” This is to see whether you have erections during your sleep (see above). If your doctor suspects a problem with penile blood flow, you may need to undergo pulsed Doppler evaluation. This test uses high-resolution ultrasound to evaluate the arteries’ blood supply to the penis. Another test involves the injection of smooth muscle relaxants through a small needle directly into the penis; the idea here is to see whether an erection can be produced. If this shot doesn’t cause an erection, this is a good hint that there’s a vascular problem—trouble with arterial blood flow Sometimes during this test a man develops an erection but gradually loses it; this usually signifies that there’s a problem with the veins—they’re not shutting off the blood supply, so the blood is escaping from the penis, and thus the erection is failing.

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Several years ago, an estrogen-related drug called estramustine phosphate (EMCYT) generated some enthusiasm among doctors in Europe for its ability to diminish testosterone and to kill some cancer cells. (This drug is related to the chemical weapon mustard gas used in World War I.) But more recent studies have shown that, although it uses different mechanisms to achieve its effects, it doesn’t prolong survival any longer than DES. And it can have side effects including nausea.

Therefore, we believe that among oral estrogens, DES is the way to go. It’s relatively inexpensive (far cheaper than some LHRH analogs, for instance) and it accomplishes the same goal as surgery—reducing testosterone to the castrate range.

Now, what’s the right dosage? How much DES do you need to take? This has been a source of great controversy in the medical community. Decades ago, doctors gave high-powered doses of DES—ten to twenty milligrams a day— thinking that this would not only eliminate testosterone, it might also kill cancer cells. This didn’t happen; testosterone was lowered, but that was it. Then, studies by the Veterans Administration showed that lower doses could achieve the same results. But even five milligrams a day proved to be too much. One study found that, over time, men on five milligrams of DES a day died— from heart disease caused by the estrogen, not from prostate cancer! Then doctors tried three milligrams, and then one milligram a day. And one milligram of DES a day proved sufficient to suppress testosterone without endangering the heart. A large study in Europe found that men on one milligram of DES a day showed no signs of irreversible damage to the cardiovascular system.

Other studies have proved that there is no statistical difference between the lifespans of men who were castrated and those who took one milligram of DES a day. (Some doctors argue that it takes three milligrams of DES a day to lower testosterone to the castrate range. This is true. However, if there’s no difference in the length of survival, and the heart-related side effects are fewer with one milligram than with three milligrams, what’s to be gained by taking the higher dose?)

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Radical prostatectomy may be considered in the small subset of men who initially had cancer confined to the prostate, if the local recurrence of cancer appears to be well- to moderately well-differentiated (a Gleason score of 7 or lower) and still confined within the prostate, and if the PSA level is less than 10. But even in these, the best possible candidates for prostate surgery after radiation treatment, the complications are much higher than for men who have surgery first. The risk of incontinence is as high as 25 percent, and other injuries—to delicate rectal tissue made even more fragile by radiation, for example—also are much more common.

Recently cryotherapy—freezing the prostate—has been considered as a “Plan B” for radiation with a rising PSA. But at the writing of this book, there is only preliminary information available on how often this affects the tumor, and on the complications that might accompany cryotherapy after the prostate has been irradiated.

The bottom line, for most patients who have a progressive increase in PSA after radiation therapy, is that it’s unlikely that any form of additional treatment will cure the cancer. One option is that these patients begin hormone therapy in an attempt to shrink the tumor (for a discussion of hormone therapy. Another is that they be followed closely with watchful waiting, and that they receive additional treatment only if or when they have symptoms of metastatic disease.

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Homosexual offenders vs. minors are adult males who made homosexual overtures to, or had sexual contact with, boys aged twelve to fifteen inclusive. As with the homosexual offenders vs. children, the number of incestuous or forced cases is so small that it has not been deemed worthwhile to establish these as separate categories of offense.

The homosexual offender vs. minors is in many respects analogous to the heterosexual offender vs. minors in that his partner is almost old enough to be considered eligible for sociosexual activity in the eyes of society. The incessant emphasis on youth and beauty, the extolment of the unwrinkled skin, the absence of adult adiposity, the vigor and enthusiasm that are dominant (and perhaps unfortunate) themes in the heterosexual sphere are also to be found in the homosexual sphere. Consequently it is not surprising to find adults with homosexual interests casting an eye upon twelve- to fifteen-year-old boys, an age group not unpopular in ancient Greece. While the heterosexual male who finds equally young girls attractive may restrain himself because of social and legal circumstances, the homosexual male is somewhat less restrained; to reverse an old saying, he feels that since he risks hanging anyway he might as well be hanged for a lamb as for a sheep. Furthermore, while the average twelve- to fifteen-year-old girl may be physically attractive and perhaps even preoccupied with vague romantic impulses, she is relatively devoid of erotic response. By age fifteen only about half of the females have recognized any sexual arousal in themselves and only about one quarter have experienced orgasm. In brief, these young girls do not ordinarly make interested and cooperative sexual partners. The adult heterosexual male suspects or knows this, and his suspicion or knowledge acts as a deterrent. The homosexual adult labors under no such handicap: by age fifteen the average boy is definitely interested in sex and is keenly aware of the pleasure to be derived from it. To be sure, this hypothetical average boy is heterosexually oriented, but he is still experimentally inclined and his prejudices and preferences have not become hardened. If such a boy can be persuaded to engage in sexual activity, he exhibits an intensity of response matching or frequently surpassing that of an adult. This fact is well known to many homosexual adults who are thereby subjected to temptation that die heterosexual adult is largely spared. If twelve- to fifteen-year-old girls had as developed libidos as boys of the same age, our penal institutions would burst at the seams.

Another element must be mentioned in connection with the homosexual offenders vs. minors. Some homosexually inclined males desire young boys not only as sexual objects but as son-surrogates; they need to find some boy to help and tutor, upon whom to lavish affection. One is again reminded of ancient Greece. In view of the wretched relationship that so many homosexual offenders had with their fathers, this humanitarianism may stem from the desire to give a boy the paternal love and guidance that they missed. To such an altruistically motivated male a boy twelve to fifteen is perfectly suited; he is not old enough to exhibit undesirable independence and yet not so young that one would have to resort to childish activities and language in order to maintain an intimate relationship. One sometimes encounters males in whom this altruism preceded any conscious homosexual desire, and who were startled to realize that their affection and interest had assumed sexual overtones. Among the most tragic cases in our records are those of men who had unstintingly devoted themselves to working with boys as teachers, camp leaders, and scout masters, and who subsequently became sexually involved with their charges and ended in our category of homosexual offenders.

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All the incest offenders vs. minors had had premarital petting experience. The median individual began petting at sixteen; only the incest offenders vs. adults began later; this belated start seems characteristic of those whose offense is against a postpubescent daughter. While the delay of the incest offenders vs. adults is largely a result of their reaching puberty at a late date, no such explanation exists for the incest offenders vs. minors, who reached puberty at a usual age. Despite their late start, the accumulative incidence (the proportions with petting experience by a given age) is in no way remarkable.

Between puberty and fifteen (inclusive) slightly over half of the incest offenders vs. minors petted: this is a low figure. Yet in the next age-period, 16-20, a large percentage (97 per cent) petted. As yet we have no explanation for the unusual abruptness of this increase. The age-specific incidence of petting to orgasm, while increasing as anticipated, shows no such abrupt rise. The figures are moderate to low in comparison with those of other groups, rising from 10 per cent in the first age-period to double that in age-period 16-20, and then falling to nearly the original figure in age-period 21-25.

These incest offenders vs. minors, like the other incest groups, did not have many petting partners; the average (median) offender had 11—the second smallest number recorded. While they had fewer petting partners than the control group, the prison group, and all but one of the other sex-offender groups, the incest offenders vs. minors cannot be said to have been seriously deprived. The same may be said of their general social relations with females at ages sixteen and seventeen, though they had somewhat fewer female friends and companions than most other groups.

In reaching orgasm through petting, the incest offenders vs. minors display the lowest frequencies (mean and median both) of any group. Sample size permits calculation only for age-period 16-20, but during these years their average frequency was only 2 to 3 times per year. There is nothing unusual about the accumulative incidence of petting to orgasm: ultimately a fifth of these incest offenders had this experience.

Their petting techniques are not particularly distinctive except that they are one of the three groups more of whose members had premarital cunnilingus with female friends (12 per cent) than were fellated (9 per cent). This latter figure is quite small; only the incest offenders vs. adults had a smaller one. The absence of any incest offender vs. minors who had had cunnilingus with a prostitute may be a matter of small sample vagary; other incest offenders display percentages that are small absolutely, but large relatively.

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The aggressors vs. minors had much the largest number of juvenile delinquents—some 56 per cent had juvenile records, and a full third (again by far the largest proportion recorded) had been committed to some juvenile institution for at least six months. This is a precocious criminal development, especially when one notes that the equivalent figures for the prison group are 24 per cent and 16 per cent—i.e., about half as large as those for the aggressors vs. minors. Their future was foretold by the fact that almost one fifth committed juvenile sex offenses, again the largest percentage to be found in all our comparative groups.

The aggressors vs. minors became involved with the law extremely rapidly. Close to one third had been convicted by age sixteen, four fifths by age twenty, and 93 per cent by age thirty; in this respect they outstripped all others including the prison group. The offenses were for the most part serious, as is evidenced by the fact that by age thirty over three quarters of the men had had one or more convictions resulting in incarceration for a year or more.

The average aggressor vs. minors was first convicted of any offense when he was seventeen; his first conviction for sexual aggressions against a minor female came later, when he was twenty-three, which is young compared to the average age of others at the time of their first sex offense.

All of the aggressors display a high number of convictions per capita, the aggressors vs. minors ranking sixth (below the other aggressors) with 3.9 convictions per man. The prison group had, it should be noted, 3.5 convictions. Over half of the convictions were for sex offenses—a proportion not unlike that of many other groups. However, relatively few (27 per cent) were “pure” sex offenders in the sense that they were convicted only for sex offenses; in this respect they are again like the other aggressors.

Examining the nonsex offenses, one sees that the aggressors vs. minors had the largest proportion of offenses against property (45 per cent) of any group except the prison group, which boasts 48 per cent. In offenses against person, these aggressors are undisputedly in first place with 18 per cent; the other aggressors are three to four percentage points less. In other sorts of offense they are either nondescript or low.

Their sex offenses were not always ones of aggression. Sometimes their sexual partners were willing—actually 28 per cent of their sex offenses involved voluntary heterosexual contact. Such offenses were committed by about 19 per cent of the men. In 24 per cent of the cases, involving about 26 per cent of the men, their aggressive offenses were not against minors but against adults. Thus far the “crossing over” from one type of offense to another appears logical and predictable. However, slightly over one third of the offenses were exhibition, which is surprising, though these were committed by only three men (i.e., 11 per cent of the aggressors vs. minors). On reflection, a certain amount of exhibition and aggression can be expected to be associated, since some exhibition constitutes a hostile act directed against females. This was recognized by a few exhibitionists themselves even before the therapists suggested such an interpretation.

The aggressors vs. minors were strongly recidivistic. Only 11 per cent, a small proportion, had one criminal conviction, whereas 26 per cent had three—the largest proportion of any group. The youthfulness of the group at the time we interviewed them explains in part why they did not have more numerous convictions, but even so some 15 per cent had been convicted seven or more times, a percentage surpassed by only three other groups.

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While more “criminal” than the offenders vs. children and adults, the offenders vs. minors in general exhibit moderate figures. By age twenty nearly half had been convicted of some offense, sexual or nonsexual, and this proportion rises to 77 by age thirty and 88 by age forty. The accumulative incidence of first offense vs. a female minor is naturally less: by age twenty, one third had such a conviction, by thirty, two thirds, and by forty, some 85 per cent. The first figure—one third—is a large one at age twenty, but the other figures are unexceptional. One may say that these offenders got off to a fast start but were overtaken later.

When the offender vs. minors committed some other sex offense he was most apt to choose exhibition; offenses against children were his next choice. The average number of sex offenses per offender vs. minors is 1.7.

In terms of sexual arousal resulting from visual stimulus, the offenders vs. minors are—like the offenders vs. adults—quite unresponsive. Only 31 per cent, the third smallest proportion, reported sexual arousal from seeing or thinking of females. Similarly, this group had the third smallest proportion of men (slightly under half) who responded to pornography. This general unresponsiveness to psychological stimuli, as opposed to physical contact, seems a product of a combination of above-average sociosexual activity, an unimaginative, simple, direct outlook on sex, and a relatively large proportion of men of below-average intelligence. Note their minimal dream content and masturbatory fantasy.

Very few offenders vs. minors were alcoholics and only a relatively small proportion of their offenses were committed while drunk. Their sobriety reflects the fact that their behavior bears little or no taboo requiring dissolution by alcohol, and in this respect they are like the offenders vs. adults. There was nothing unusual about their use of drugs. They are, however, quite distinctive in gambling; while half of them (the same proportion as among the control group) did not gamble, those who did tended to do so seriously. Some 22 per cent, a figure second only to that of the prison group, derived a substantial part of their income from gambling.

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