In addition to these tried-and-true forms of treatment are many new techniques for treating BPH. One of these is balloon dilation, although its popularity seems to be waning—mainly because its effccts don’t appear to be long-lasting. Other new treatments channel energy—heat, radio frequency, ultrasound, microwaves, and light— to kill the overgrowth of prostate cells surrounding the urethra. Some of these energy waves work like a shotgun, blasting holes in the prostate. Others are as sensitive as a scalpel, delicately nibbling away at BPH tissue until the urethra is free. Among these new techniques are transurethral microwave thermal therapy (TUMT), lasers, high-intensity focused ultrasound (HIFU), transurethral needle ablation (TUNA), and pyrotherapy. The goal of these techniques is to achieve the same result as with a TUR but with less anesthesia, less bleeding, and a shorter hospital stay.

Preliminary evaluation of these techniques suggests the relief of obstruction they bring may not be as pronounced as that achieved with TUR, and it’s not clear whether this relief will be as long-lasting. However, as these new techniques evolve, it’s likely that their results will improve.

An attractive option for older patients, or men in poor health who aren’t candidates for more aggressive therapy, is mechanical—special tubes called stents that hold the prostate open to relieve the squashed urethra.

*298\201\8*

Dry” Ejaculation may happen in as many as 75 percent of men after TUR. It has nothing to do with sexual performance, and does not change the pleasant sensation of orgasm.

*259\201\8*

Why does impotence occur? There are main possible reasons, in addition to the fact that a man has had prostate treatment. Aging is one reason for impotence. But impotence can also result from medical c< mdirii ms such as diabetes or hypertension, from certain medications, from overuse of alcohol, cigarettes or other drugs, even from emotional or psychological problems.

The bottom line is that for most men, impotence does not have to be a permanent situation. If there’s a will, there’s generally a way.

What can go wrong? Normal sexual function in men has four components—libido (sex drive), erection, emission of fluid (ejaculation), and orgasm.

*222\201\8*

Finally, other studies have demonstrated that adrenal androgens have little effect on the prostate. In one investigation at Johns Hopkins, researchers studied four men who had their pituitary glands removed before they reached puberty—which means that not only did their bodies fail to make LH, they failed to make a hormone that stimulates the adrenal gland, so it was virtually shut down; in other words, they had total androgen blockade. They also studied three men who had a genetic disorder called Kallmann’s syndrome (in which the hypothalamus doesn’t make LHRH, and therefore, the pituitary glands don’t make LH or FSH), and one unfortunate man who had been castrated at age seven, when a dog bit off his testicles. The average age of these men was about 65. Using age-matched “control” (normal) patients for comparison, the investigators showed no disparity in prostate size’in men with both testosterone and the adrenal hormones out of commission and in men with only testosterone missing. (In all of these men, the prostate was tiny. In all, there were no Leydig cells, the tiny testosterone-making factories in the testicles.) In other words, total androgen blockade made no difference.

*183\201\8*

One transperineal approach involves open surgery and begins much like the radical prostatectomy—with a Foley catheter, an abdominal incision and a staging lymph node dissection (see Chapter 3) to make sure the cancer has not spread to the pelvic lymph nodes. If the lymph nodes are cancer-free, the procedure continues. When doctors reach the prostate and can see the tumor, they draw an outiine by implanting tiny bits of material, which can be seen on an X-ray, around its edges—like dotted lines or stakes marking a boundary. Then the doctor inserts a long needle through the perineum into the prostate, far enough so that its tip sticks out of the bladder neck. This is called a stabilizing needle, and it becomes an axis that helps hold a template in place. The result is a highly sophisticated kind of “paint-by-numbers” map of the prostate that helps doctors know exactiy where to insert the other needles. The doctor’s finger, inserted in the patient’s rectum, helps guide placement and depth of the needles. With this approach, it’s also possible for doctors to place seeds in the seminal vesicles (however, this may cause severe rectal complications.

Now, instead of simply inserting the radioactive seeds, the doctors send the patient out of the operating room and to the hospital’s radiation oncology department. “Dummy” (not radioactive) seeds are implanted, and then photographed by an X-ray machine. These fake seeds make possible ultra-precise, three-dimensional placement of each of the real radioactive seeds, which are implanted next. Also, the amount of radioactive material can be fine-tuned from seed to seed to ensure an even distribution of radiation. Now comes a little help from outside—external-beam radiation therapy. The radiation zeroes in on the implants and turns them into little antennae, which help focus and amplify the radiation. The seeds are removed—which should minimize the risk of infection—and a course of external-beam radiation therapy will begin two to four weeks later.

*145\201\8*

The frequencies of extramarital coitus, calculated only for those who had such coitus, are moderate to low. The average (median) offender had it with six females—a moderate number. The proportion of total outlet derived from extramarital coitus is the smallest reported by any group, never more than 3 per cent.

As one might guess, comparatively few of the homosexual offenders vs. minors continued to have heterosexual coitus after their marriages broke up. Some 72 to 86 per cent did so, but these are relatively small figures. Those with postmarital coitus had such activity with rather low frequencies—0.4 to 0.6 a week—and twice rank lowest of all in this respect. Consequently, only a small proportion of their total sexual outlet (roughly one quarter to one third) was derived from postmarital coitus with companions. Some 6 to 13 per cent of their orgasms between ages twenty-six and forty-five were from postmarital coitus with prostitutes; in this respect they are not unusual, although it is a bit surprising to find them ranking second (with 9 per cent) in age-period 26-30.

*189\161\2*

They became involved with the courts very slowly as is typical of incest offenders: by age twenty only 20 per cent had been convicted (most other groups range from 30 to 80 per cent in this respect), and by age thirty 43 per cent (only the incest offenders vs. adults exceed them). Some of this belated involvement with the law stems from the nature of their specific sex offenses: not many men of thirty or less have daughters aged twelve to fifteen. This is evident also in the incidence figures for convictions resulting in sentences of a year or more; very few had such convictions on their record until they reached the necessary age. The median age of first conviction for any offense was 35 years, the median for the first incest offense vs. minors was 38 years. Both ages are the second oldest recorded, being exceeded by only the incest offenders vs. adults.

Slightly over half of the convictions were for sex offenses. About the same proportion of men had been convicted solely for sex offenses. This is comparatively a large figure and one shared by the incest offenders vs. adults. The general noncriminality of these offenders is evident also in the per capita conviction calculations. Total per capita convictions were 2.6, the second (to the incest offender vs. adults) smallest number to be found among our comparative groups. The per capita sex-offense convictions were 1.4, the third smallest.

Like other incest offenders, their nonsexual offenses emphasize crimes vs. order and minimize crimes vs. property. The crimes vs. order are a miscellany that defies description; one can only say that they do not clearly constitute crimes against persons or property nor are they in the realm of drunk-vagrant offenses. Examples of crimes vs. order will be given in the chapter on criminality.

The sexual crimes, other than the specific offense of incest vs. minors, are rather few and were equally divided between heterosexual offenses and heterosexual aggressions (28 per cent each). A smaller number of offenses were similarly divided between incest with younger and older daughters (17 per cent each). A few exhibition offenses (11 per cent) complete the picture.

As one might deduce from the foregoing, the incest offenders vs. minors are not recidivistic in comparison to most other groups. Some 42 per cent had but one conviction—a good record for a group with the second highest age (nearly forty-one) at the time of our interview.

*147\161\2*

The tendency to have high frequencies of masturbation before marriage, which we saw in the aggressors vs. minors, is seen again among the aggressors vs. adults. The mean frequency remains high between the ages of twenty-one and thirty. The average (median) individual occupied an intermediate to high-intermediate position in the rank-orders up to the age of twenty-five, but leaped to third rank during age-period 26-30 with an absolute as well as a relative increase in masturbation frequency. In any age-period, regardless of whether one views the mean or median, the aggressors vs. adults masturbate with considerably more frequency than the controls.

The tendency to rise in rank-order with increasing age seems a trait of the aggressors vs. minors and adults, and suggests some unfulfilled sexual needs. The abrupt increase in frequencies between the ages of twenty-six and thirty displayed by the aggressors vs. adults is ominous, especially since their premarital coitus diminished at this time. Among the married aggressors vs. adults who masturbated while married, this same increase at twenty-six to thirty is noted in the calculation of average (mean) frequency: the increase is from roughly twice a month to 5 times a month, the third highest frequency recorded for this age-period. This change is, however, not reflected when one calculates the masturbation frequencies of the average (median) aggressor vs. adults, which are neither high nor low.

The proportion of total outlet derived from masturbation shows an interesting change. In both the never married and the married the proportions are moderate or even a bit low until age-period 26-30 when they increase, with the result that those who were never married achieve second place in the rank-order with 49 per cent of their outlet being masturbatory, while the married men reach third place with 10 per cent. In the following age-period the never married drew somewhat less of their total outlet from masturbation (39 per cent, fourth in rank-order) but the married drew even more, reaching second place in rank-order with 13 per cent of their orgasms from masturbation. This emphasis on masturbation among both the single and married after age twenty-six is unusual in a heterosexual group, and quite unlike the two control groups.

Like the heterosexual aggressors vs. minors, the aggressors vs. adults were unusually prone to fantasy. Moreover, they rank second only to the aggressors vs. minors in the percentage with sadomasochistic (9 per cent) fantasies—an omen of the offenses for which they were ultimately convicted. This high rank with regard to sadomasochistic fantasy we shall see parallels their responsiveness to sadomasochistic-stories and pictures.

The aggressors vs. adults were less prone than other aggressors to worry over their masturbation, but nevertheless fall in the upper half of a rank-order of “worriers.”

*105\161\2*

The single offenders have moderate age-specific incidence figures for nocturnal emissions except in age-period 26-30 when they rank first with a surprising 78 per cent. In the next age-period, 31-35, they return to their usual intermediate position in the rank-order.

While fewer of the married offenders vs. adults experienced nocturnal emissions in any age-period up to thirty-six than did the married members of the prison or control groups, at older ages they surpass these two groups. This unexpected and marked increase after thirty-five is unique and inexplicable, and puts them at the top of the rank-order in age-period 36-40 (53 per cent) and age-period 41-45 ( 67 per cent).

While a large proportion of offenders vs. adults had nocturnal emissions, they had them with only moderate frequency. In both median and mean measurements of average frequency they are intermediate with respect to other sex offenders, but far below the control group. Their third rank at ages twenty-six to thirty in mean frequency should be disregarded, since it results from the activity of one very unusual individual. The average (median) unmarried offender vs. adults experienced 4 to 5 nocturnal emissions a year after age fifteen.

The proportion of total sexual outlet constituted by nocturnal emissions is unexceptional among the never married until age-period 26-30 when one individual’s extraordinarily high frequencies increase the proportion markedly. If this lone male is disregarded, the proportion of total outlet derived from nocturnal emissions remains moderate to low among the single males.

The married men, on the contrary, found relatively large proportions of their total outlet in such emissions: the married offenders vs. adults rank from second to fourth from age sixteen to thirty-five and second from age forty-one to fifty. The actual figures are, of course, small, as is true for all married groups, ranging from 2 to 6 per cent.

The previously married but currently unmarried males display moderate percentages in all age-periods, ranging from 3 to 5 per cent.

*63\161\2*

The varying proportions of Protestants and Catholics in our groups reflect, insofar as we can determine, the religious distributions in the geographic areas where we worked, and have little or no connection

with behavior. However, in the case of the Jews, we agree with previous studies that there are elements in Jewish culture and family life that militate against the commission of crime. There are simply far too few Jews in our prison and sex-offender groups to be explained in any other way. In only two sex-offender groups do the Jews constitute as much as 2 per cent: these are the homosexual offenders, as one could have anticipated, for it is only in this realm of behavior that no one can find a legal sexual outlet.

As a rule, in the prison and sex-offender groups there are fewer religiously devout than moderately devout individuals, and that those who are rated as inactive in their religion are most numerous of all. In some respects this only mirrors the fact that in or out of prison the religiously devout are always a minority. It also indicates that with increase in devoutness there is usually a decrease in behavior rendering one liable to conviction. There are a number of exceptions to this: sometimes a certain sex-offender group contains more moderately devout than inactive individuals.

In the control group among the Protestants the number of moderately devouts and the number of inactives are nearly equal, with the devouts constituting a minority of 16 per cent. Among the Catholics, however, our sample contains more devout individuals than moderates and more moderates than inactives. This undue proportion of religiously devout was the result of the hospital sample which, being in the northeast part of the United States, contains more devout Catholics than would have been encountered elsewhere.

Disregarding the type of religion and examining solely the degree of devoutness, we find that in the control group 36 per cent are inactive, 35 per cent moderately devout, and 28 per cent devout. Quite different proportions obtain in the prison group, the equivalent percentages being 59, 26, and 15. Taken as a whole, the sex offenders approximate the prison group, but among the sex-offender groups there is great variation. The range extends from the least religious, the offenders vs. adults (64 per cent inactive, 12 per cent devout), to the most religious, the incest offenders vs. adult daughters (36 per cent inactive, 40 per cent devout).

*20\161\2*