Weight loss and diet plan for a healthy lifestyle.

Again, this phase is one from Neighbour’s model (1987), although he calls it ‘safety-netting’, an expression which may not be immediately clear to everyone. This phase involves agreeing an outline of further management and the timing of the next appointment. Equally, it is important to make clear how to gain access to the doctor or nurse in the event of any difficulty, the symptoms which a patient should report immediately and the possibility of changing contraceptive method if the proposed method does not suit.

*350/197/1*

Complaints that the method of contraception is affecting sexual performance or desire, especially if frequently presented, can indicate a problem within the relationship which the patient does not wish to face. The anxieties are focused on the method of contraception; the fantasy is that, if only this could be made all right, so would the relationship. Doctors are often aware that underlying relationship problems may be behind the request for sterilization or vasectomy (or to stop contraception to have a baby to ‘mend’ the marriage), but sometimes forget that such difficulties may be behind an otherwise reasonable-sounding request.

*311/197/1*

Some women of any age find it hard to ask for help which is essentially help to be sexual. The older woman may find it harder because of a perception within herself that sex is for the young, or because of a feeling that the doctor will disapprove of sexuality in someone of her age. The widowed and the divorced may have an added sense of disloyalty, especially if the previous partner was known to the doctor. For women with an extramarital partner, especially if the husband has had a vasectomy, the problem is even greater.

A request for postcoital contraception may also be difficult. It may be forgivable for the young to make mistakes or get carried away in a moment of passion, but there is a feeling that at over 40 society expects you to know better. Or perhaps it is a feeling that society does not expect you to have strong, that is sexual, feelings at such an age. Yet women in this situation have to approach an authoritative member of society for help. It must not be forgotten that doctors are still seen as authority figures. In this context it may be particularly difficult to approach the general practitioner, however good and sympathetic he may be. Indeed, this very goodness and concern for the patient can be a barrier. Most people want their regular doctor to see them as a sensible and competent, and it can be particularly difficult to expose the silly side of oneself to the person who will be providing continuing medical care. An alternative source of help, where the patient need never return unless she wants, is vital.

*273/197/1*

Saeeda Nessa had lived in the UK since 1983. Five children had been born between 1975 and 1983, and any space between pregnancies had arisen because of her husband’s visits to the UK. Since living with her husband in London, she had had a baby every October, all boys. She had a past history of pulmonary tuberculosis, leaving her with partial bronchiectasis and recurrent bronchitis. Her husband, who always accompanied her to the surgery, was rather demanding and overbearing with reception staff, and frequently referred to the Race Relations Act if they did not accede to his peremptory requests. The GP’s attempt to discuss contraception during the gestations of the 1987 and 1988 babies were repudiated by him with the rules of Islam. The religious laws were never confronted directly by the GP, but longer experience of this man revealed that his bark was worse than his bite and that the family was not in such awe of him as might at first appear. The message about contraception was respectfully but relentlessly put. Saeeda finally came without her husband, but with his tacit consent, for her first discussion about contraception. It is now four years since her last child was born and her husband smiles wryly whenever the doctor checks with Saeeda about her contraception.

Conversely, a physical symptom or other problem may be presented as the reason for not getting on with a method, in order to avoid discussing cultural issues. A consciousness that one’s culture’s general opinions about coils or Pills are held to be ridiculous by a sophisticated westerner may also incline one to pull down the cultural shutter.

*235/197/1*

Feelings of diffidence in the doctor may come from within, but are often a reflection of the patient’s diffidence. There can be a strong feeling of the need for approval on the patient’s part, and from the doctor’s viewpoint there seems to be a need to be the permission giver. When people have disabilities there is a sense in which their body no longer belongs to them, for other people take it over and do things to it. It is difficult for the patient to obtain or accept responsibility for his own choices and actions. Such a handing over of responsibility is particularly common when there is a mental handicap, where the expectation of compliance is an everyday experience, the person being expected to do as he is told and to have decisions made for him.

Encouragement by the doctor to explore choices and to make decisions, to try, and to see the act of trying as a success, is the greatest help. The person may need to return again and again for the continued reassurance that ‘it is OK’. There is a hint of seeking parental approval, but with encouragement a growth of confidence and the acceptance of a sexual role can develop, as well as an ability to make worthwhile relationships.

*197/197/1*

Five males (aged seventeen to nineteen) and the eighteen-year-old offender picked up a nineteen-year-old girl who had missed the bus home from an amusement park. After parking near the river two of the males went off to swim and the other three persuaded her to have coitus. She finally agreed and got into the back seat. One male attempted intercourse without success, but the second succeeded. The present offender claimed he only held the door open for her. As she was a virgin, she bled profusely and later charged rape against all five males. Here, while all the males were accessories, only two were apparently directly involved in the sex behavior.

An eighteen-year-old male and three companions en route home from a party all had coitus with a nineteen-year-old girl who was in the car with them. They were chased by the police and apprehended. The final conviction was based on their buying alcohol for another seventeen-year-old girl, but it was a direct result of the earlier event. The nineteen-year-old girl had given evidence, and, hence, was not involved in the charge.

Six army buddies, plus the offender, aged twenty-two, had a drinking party on the beach. It ended in their attacking a dating couple and attempting intercourse with the female. The offender claimed he did not have intercourse but admitted his fly was open, and he was charged with holding the girl’s head down while she was raped by a companion.

A twenty-two-year-old male and four friends picked up an eighteen-year-old girl and her girl friend. The latter was let out and the party continued into the hills, drinking. The girl accused the males of forceful coitus, but since medical examination showed her hymen to be intact, coitus was apparently attempted rather than completed.

*373\161\2*

Every human being is continuously assailed by numerous stimuli, which he must interpret in order of importance, kind, and intensity. Because of our physiological and cultural uniformities we tend to make similar interpretations. Certain stimuli are usually interpreted as sexual in content and sexually arousing in effect. Such stimuli command attention and consequently are much used in the media of mass communication and entertainment.

In the years just after puberty, especially, many stimuli produce sexual arousal and even orgasm in males. The threshold of sexual response is low and selectivity relatively undeveloped. In young mammals one often sees general excitement transmute into sexual excitement, and this same ability is found in many young human males and probably in some females as well. With increasing age and experience the individual responds much more selectively and less readily, partly because of physiological deterioration and partly because of psychological fatigue: the desire becomes the familiar and the familiar becomes the monotonous. Often a novel stimulus of lower intensity than a familiar stimulus will produce a more rapid and intense response.

The interpretation of and response to various stimuli is often so subjective and complex that thus far the Institute for Sex Research has undertaken only limited and quite crude investigations of both contact (which we shall term “physical”) and noncontact (“psychological”) stimuli and resultant response. As far as physical stimuli are concerned, we have generally assumed some degree of sexual arousal and also a high positive correlation between the frequency of, preference for, and intensity of response from certain techniques. Nor have we investigated in any degree the so-called “erogenous zones,” except for a study of female genital sensitivity which is not synonymous with erogeneity. These are matters that will claim some of our attention in subsequent research.

Without becoming entangled in the definition of intelligence, we wish to observe that it is obviously involved in psychosexual arousal, and that we have collected information on the intelligence of the majority of males comprising this study. For the incarcerated males this information was obtained from the official records, which expressed the degree of intelligence either in terms of various psychometric tests or in summary descriptive labels such as “feeble-minded,” “moron,” “dull normal,” “above average,” “superior,” etc. When no official information was available (as was the case for nearly all the control group), we relied upon the brief descriptive notes we append to every case history at the time of the interview.

For practical purposes we condensed the data into four categories: feeble-minded (IQ-70), below-average (IQ 71-89), average (IQ 90-109), and above-average (IQ 110-f-). As might be expected, about half the control group fall in the average category and the others are more or less equally divided into above- and below-average. The prison group and the sex offenders present quite different distributions.

It is difficult to draw meaningful conclusions from these data. One can say, however, that of the tripartite groups the heterosexual offenders are the dullest (from 45 to 49 per cent were below the category of average), while the homosexual offenders were the brightest—roughly one third to two fifths rated as above-average.

The heterosexual offenders were joined by the peepers and by the aggressors vs. children to constitute the five dullest groups, while the five brightest include, besides the homosexual offenders, the incest offenders vs. children and the prison group. There is a strong correlation between intelligence rating and completed education. The five brightest groups also include the three with the largest proportions of college-educated, and four of the five groups with the largest proportions of persons with 11 and 12 years of education. Conversely the five dullest groups contained those with the poorest educations. This is not wholly a cause-and-effect relationship; certain forms of sample bias are also involved. Thus the homosexual offenders contain a large number of better educated because many were interviewed outside prison and came from a more favorable social milieu. On the other hand, the heterosexual offenders were, in comparison, far more rural and financially poorer.

The chief value of these intelligence data in this study lies in their explicating our findings concerning fantasy and psychosexual response.

Of the various noncontact stimuli—olfactory, gustatory, auditory, visual, and fantasy—we have concerned ourselves almost exclusively with the latter two. Our questions regarding visual stimuli were simple: we asked whether or not and to what degree the person was sexually aroused by seeing adults of the same and opposite sex, either in the flesh or in pictures, in various conditions of nudity and sexual activity. Naturally the questions and responses were highly interrelated; for example, a male who reported sexual arousal from seeing females also reported arousal from seeing nude female art, strip-tease, and representations of heterosexual activity. Because of this uniformity we decided to use in this present study only a few of the questions regarding visual stimuli. First, there is a general basic question: was the individual aroused, and to what degree, by the sight of other adult humans under ordinary conditions, as on the street or at a social gathering? It must be noted that even this seemingly simple question, “Does it arouse you sexually to see women (or men)?” is fraught with all manner of assumptions and qualifications about time, place, dress, physique, etc., and, to make matters worse, we considered frequency and intensity as equivalent. Despite these numerous and serious qualifications, and pending more sophisticated investigation, this question does afford worthwhile gross data. Second is the more specific question whether the individual was sexually aroused by pornographic photographs or drawings. The usefulness of this question is limited by psychologic conflict: the person may reply that he is not aroused, but is upset or disgusted—emotions which stem from a conscious or unconscious erotic response to the pornography. Nevertheless, such a reply was recorded as a negative. Because of the suggested connection between sex offenses and pornography we also inquired whether the person had owned pornography or had merely been briefly exposed to it. The third question is “visual” only in part: was the individual aroused by sadomasochistic pictures or stories?

The other area of psychological stimuli, fantasy, we have already treated in questions concerning sexual dreams and masturbation fantasy. In addition, we asked everyone we interviewed a more general question: “Are you aroused by thinking of the opposite (or same) sex?” This is the equivalent of asking, “Do you have sexual daydreams of the opposite (or same) sex?”

Before going on to describe our findings, one more complication needs to be discussed. While it is no surprise to find individuals who do not respond to specialized stimuli such as sadomasochism, or individuals whose inhibitions produce a negative rather than a positive response to blatant sexual stimuli, it is surprising to find substantial percentages of heterosexually active individuals who report no arousal from seeing or thinking of members of the opposite sex.2 Were these reports actually true, one would have to believe there were equivalent percentages of people who responded only to physical stimuli, who were never aroused by recalling past sexual experiences, and who never initiated sexual activity unless previously aroused by physical contact. Fortunately, we are not required to believe this. The truth of the matter is our questions were so phrased that only moderate to strong responses were counted as affirmative, and a mild response was almost certain to be recorded as negative. For people in the more educated upper socioeconomic level we used the phrase, “Does it arouse you sexually to . . . ?” while for the lower socioeconomic level we not infrequently used the phrase, “Does it make you (or get you) hot to . . . ?” This phraseology implies a considerable degree of sexual arousal to most persons. Indeed, if a person, when queried, asked for a clearer definition of arousal, we mentioned increased pulse, increased respiration, cutaneous warmth, etc., all of which are symptomatic of a rather intense or prolonged arousal:

Consequently, we cannot at present say how many heterosexually active individuals do not respond sexually to seeing or thinking about members of the opposite sex, and this statement also applies to the response of the homosexually active to the same sex. However, we can say definitely how many respond strongly and/or frequently, moderately and/or occasionally, and formerly (degree unspecified) but not currently; we can then provide a residual category for those who respond little or not at all. In this category of “little or none” we recognize that the “nones” are extremely rare in youth, but increase with age so that by perhaps the fifth decade of life the term “rare” is no longer appropriate, at least for males. A “none” report may be safely accepted when one notes that the person also no longer has sexual dreams or fantasy and has little or no overt sexual activity.

*335\161\2*

Among those who had premarital coitus with companions, the heterosexual offenders vs. adults usually lead in the tables showing median frequency, followed by the prison group and offenders vs. minors. The aggressors vs. adults also tend to rank somewhat high. A considerable frequency gap usually separates the offenders vs. adults from the second ranking group; aside from this, the order reveals a reasonably gradated sequence with the control group in the middle. At or near the bottom are the homosexual offenders. However, the peepers, who were low in incidence of premarital coitus, are not low in terms of frequency. This is because we are dealing with “active” frequency, much of which consists of the coital frequencies of the sexually active subgroup of peepers. The same appears true of the incest offenders vs. adults in the one age-period for which we have data. In brief, the incest offenders vs. adults and the peepers who had premarital coitus had it with moderate frequency.

In mean frequency of premarital coitus with companions, a similar situation prevails. The offenders vs. adults generally lead, with the prison group and offenders vs. minors following, and the aggressors vs. adults sometimes close behind. Unlike the median frequency, in the mean-frequency calculations the control group moves from a low rank up to second rank between ages twenty-six to thirty, when the offenders vs. adults inexplicably pause in their coital activity (resuming their usual frequency later) and the offenders vs. minors and aggressors vs. adults also curtail their activity.

As usual one sees the homosexual offenders low in mean frequency of premarital coitus with Companions—particularly later in life when, so to speak, the sexual die has been cast—but they are joined by two unexpected groups. The frequencies of the aggressors vs. children can be calculated only for age-periods 16-20 and 21-25, and in both this group occupies the lowest rank; their incidence figures gave no warning of this. The incest offenders vs. minors also are at, or second from, the bottom in the rank-orders wherever data for them exist.

At this juncture it is necessary to make explicit one of our assumptions. We have felt that a positive correlation should exist between incidence and frequency. Thus if the incidence figure of a group is high for a certain sexual activity, we feel that this probably indicates a high interest in die activity, and logically a high interest should result in high frequencies. In a rough way this assumption can be justified by our data. For example, the homosexual offenders vs. adults have both low incidences and low frequencies of premarital coitus with companions whereas the heterosexual offenders vs. adults and the prison group have high figures. However, in particular groups and at particular ages this correlation between incidence and frequency is weak or absent.

The frequencies of premarital coitus with prostitutes are less than the frequencies of premarital coitus with companions. The frequency data concerning premarital coitus with prostitutes often do not agree with the incidence data. The highest median frequencies are displayed by the homosexual offenders vs. children, and the heterosexual offenders vs. adults and minors. The highest mean frequencies are those of the heterosexual offenders vs. adults. By and large there are no cohesive tendencies or outstanding trends; the tripartite groups are usually scattered through the rank-orders, and the age-of-object (child, minor, adult) categories are similarly distributed. One gains the impression that the frequency of coitus with prostitutes often depends upon paradoxical and sometimes fortuitous factors. It can be on one hand a sort of “spillover” on the part of a very active heterosexual group, representing a psychologically and numerically unimportant part of life; on the other hand, for another group, it may represent a substantial or major part of their heterosexual activity and be of extreme importance. One means of telling which of the two possibilities is applicable is to consider simultaneously the ratio between the proportion of total outlet derived from premarital coitus with companions and that derived from prostitutes, and die median frequency of total premarital coitus. Taking age-period 21-25, one finds that the four groups with the highest frequencies of premarital coitus have total outlet ratios wherein coitus with companions outweighs that with prostitutes by 5 to 1, 7 to 1 (two groups), and 8 to 1. For these groups, prostitution may be assumed to represent a “spillover.” The four groups with the lowest frequencies of premarital coitus have total outlet ratios of 4 to 1, 2 to 1 (two groups), and one group derived more outlet from prostitutes than from companions. These groups would exemplify those wherein prostitution was an important part of sexual life.

*297\161\2*

The average (median) persons of the control and prison groups reached puberty at 13.8 and 13.6 years of age respectively. Puberty is here identified with the development of pubic hair and the ability to ejaculate; a more detailed definition is to be found on pages 182-189 of our earlier volume, Sexual Behavior in the Human Male. Puberty is, of course, one of the major turning points of life, and as such has been publicly noted and celebrated in some fashion by most human societies. At this time the boy acquires not only physical secondary sexual characteristics, but also a whole new set of obligations and privileges. However, societies often define puberty on a social rather than a purely physical basis, and of a group of boys undergoing tribal puberty rites a number may still be prepubertal and others may have reached puberty several years previously. Similarly, while our own society treats puberty as an important dividing line, we too tend to define puberty rather arbitrarily. The boy who reached puberty at ten gets into the theater at age twelve on a child’s ticket, whereas the prepubescent thirteen-year-old must pay an adult admission fee. The wearing of certain sorts of clothing and cosmetics is an age-graded affair with chronological age (socially defined puberty) being as important a factor as physiological status. This use of social rather than physiological puberty raises a number of problems for the unfortunate children who attain puberty far in advance of or long after the socially determined age, which in our society roughly coincides with the average age of physiological puberty, i.e., around thirteen to fourteen in boys and a year earlier in girls. Society has made no provision for the boy who reaches puberty at nine or ten; his intensified sexual needs are ignored or looked upon as problems verging upon the pathological. The boy with belated puberty suffers from the gibes of his peers and is often thrust by social pressures into unwanted dating and dancing.

The group with the most delayed puberty—the median person attaining it at age 14.5 years—is the incest offenders vs. adults. Following in order are the heterosexual offenders vs. minors, the heterosexual aggressors vs. children, and the heterosexual offenders vs. adults. The most precocious group is the homosexual offenders vs. adults (13.1); in fact, the average individual of all homosexual-offender groups reached puberty relatively early, between 13.1 and 13.6 years of age.

Whereas only 24 and 31 per cent of the control- and prison-group members reached puberty before age thirteen, no less than 47 per cent of the homosexual offenders vs. adults did so, and a relatively large proportion of the other homosexual offenders. At the other extreme, those who reached puberty at or after age fifteen, we find the incest offenders vs. adults leading with 39 per cent, trailed by the aggressors vs. children and offenders vs. minors.

This phenomenon of early puberty in the homosexual offenders suggests that if the sexual drive develops at an age before society sanctions heterosexual activity, the drive, blocked from heterosexuality, may turn toward homosexuality. In this connection it is noteworthy that the heterosexual aggressors vs. minors, whose median individual reached puberty at the second youngest age, are also second only to the homosexual offenders in the percentage with both prepubertal and postpubertal homosexual experience.

*259\161\2*

Singularly few of the peepers had sex dreams. Of all groups, they had the smallest number (73 per cent) who had experienced nocturnal emissions. In age-specific incidence they also are very low. For example, during age-period 16-20 when nocturnal emissions are at their peak and when from 55 to 79 per cent of the single members of other groups were having them, only 52 per cent of the peepers experienced these “wet dreams.” Too few peepers married to permit age-specific calculations for that portion of the sample.

Even when one examines only those peepers who did experience nocturnal emissions, it is evident that the frequency was low. This is most clearly seen in the calculation of average (mean) frequency in various age-periods from puberty up to age thirty: the peepers are in the lowest or next to lowest position in the frequency rank-orders with rates of only 5 to 10 nocturnal orgasms per year. In terms of median frequency, they are like other sex offenders.

As one could surmise from the above, the proportion of total sexual, outlet the peepers derived from nocturnal emissions is extremely small. The unmarried peepers have either the smallest or nearly the smallest proportions (1-5 per cent) recorded from puberty on to age thirty, after which we have no further data.

In dream content this same deficiency is evident. Nearly one fifth, the largest proportion on record, reported that their emissions were unaccompanied by dreams. Similarly, in the percentages who had homosexual and animal contact dreams the peepers are low in the rank-orders. None had sadomasochistic dreams despite the fact that 8 per cent had sadomasochistic masturbatory fantasies. In short, the tendency displayed by peepers for exotic fantasy is not reflected in their dreams.

*220\161\2*