• Watchful Waiting Alpha Blockers

    Finasteride

    TUR

    Chances of symp-

    31-55% 59-86%

    54-78%

    75-96%

    tom improve-

    ment for at

    least one year

    Risk of immedi-

    None 3-43%

    14-19%

    5-31%

    ate complica-

    tions

    Immediate risk of

    None None

    None

    0.7-1.4%

    incontinence

    Risk of impo-

    Probably no additional risk; how-

    Can cause im-

    3-35%; how-

    tence

    ever, without any treatment,

    potence in

    ever, doctors

    one out of fifty men age 67 and

    about 5% of

    think the

    older, per year, loses ability to

    men; this is

    risk for most

    get an erection.

    reversible

    patients is

    and should

    5-10% and

    disappear

    actually may

    when the

    be no higher

    drug is

    than with

    stopped.

    watchful

    waiting.

    Need for future

    15-65% over 3 6-54%

    Unknown

    9-11% 5 to 8

    treatment

    to 5 years

    years after

    treatment

    Loss of work and

    1 day 3.5 days

    2 days

    7-21 days

    activity time

    during first

    year of treat-

    ment

    Source: The U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research.

    *294\201\8*

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  • The prostate’s innermost core is removed, usually after spinal anesthesia (see above), without opening up the abdomen. This operation, called a TUR procedure, is a proven, effective way to improve BPH symptoms quickly, and keep them at bay for years. In a TUR procedure, surgeons reach the prostate via the urethra by placing an instrument like a cystoscope through the penis. This instrument, called a resectoscope, shines a powerful light that allows surgeons to view the prostate as they chip away at excess tissue. (This tiny instrument even has its own “windshield wiper,” which irrigates the lens and keeps the area clear for surgeons to see.) The prostate’s core is removed in fragments, by means of electrosurgical cautery. These tissue chips amass in the bladder, and at the end of the procedure, they’re flushed out, collected and sent to a pathologist for examination. Because the resectoscope is threaded through the urethra, no skin incision is needed.

    After Surgery

    A Foley catheter is inserted into the urethra and the bladder is continuously irrigated with a salt solution for the first twenty-four hours to prevent blood clots from forming. This catheter is usually removed in two to three days. The average hospital stay is one to three days. Most men have little or no pain after a TUR. When pain does occur, it’s usually because of bladder spasms, involuntary contractions of the thickened bladder around the Foley catheter. These usually go away when the catheter is removed. You should be feeling fully recovered in about three weeks.

    *255\201\8*

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  • The idea here is to create suction using an airtight tube that is placed temporarily around the penis. An attached pump withdraws air, creating a reduced atmospheric pressure—a vacuum—around the penis, causing it to become engorged with blood. The penis becomes erect. Then a constricting ring, like a rubber band around the neck of a balloon, keeps the blood trapped in the penis, so the erection can be sustained. (This imitates the clamping action of the veins in normal erection.) It usually takes about five minutes to produce the erection, and this generally lasts for about half an hour. (The erection probably shouldn’t last much longer than that; leaving the constricting band on too long can cause distention or swelling due to fluid retention in the penis.)

    This erection is not quite the same as a normal erection—it begins only above the constricting band. But it is sufficient for successful intercourse. Vacuum devices have few complications; these can include trouble with ejaculation, pain in the penis, and tiny, pinpoint-sized bruises. (Men taking aspirin or other blood-thinning medications may be more likely to experience such complications.) Some men are highly satisfied with the result of vacuum devices; others are not.

    *218\201\8*

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  • Ketoconazole

    This drug got its start as an antifungal agent. Then doctors noticed that men taking it developed breast enlargement—clearly, more than fungal problems were being treated here! Doctors learned that ketoconazole blocks production of testosterone by the testicles as well as androgens made by the adrenal gland. It works quickly; taking 400 milligrams of ketoconazole every eight hours reduces testosterone to the castrate range within twenty-four hours. The drug’s effects are reversible, and testosterone goes back up again as soon as a man stops taking ketoconazole. It’s debatable whether the drug is as effective as other hormonal treatments for long-term use; ketoconazole causes a surge in production of LH that might, over time, overpower the drug’s tight clamp on testosterone. Therefore, ketoconazole generally is used in short-term situations where fast action is needed—in a man with acute spinal pain, for example, or in a man with DIC (disseminated intravascular coagulation, a blood-clotting disorder that develops in some men with advanced prostate cancer). In addition to the hormonal effects, some derivatives of ketoconazole have also been shown to have some effect in directiy blocking the growth of cancer cells; this potential is undergoing intense investigation. One technicality: The drug is not approved by the FDA for use in the treatment of prostate cancer. It can have adverse effects on the liver. Because it can also suppress the production of steroids normally produced by the adrenal gland, ketoconazole should be prescribed along with a corticosteroid such as prednisone (five milligrams a day), to compensate for this loss.

    Conclusion: Ketoconazole is not a drug for the long haul, but it is helpful in some situations.

    *179\201\8*

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  • Recently, investigators at Johns Hopkins studied 51 radical prostatectomy patients who experienced a rise in PSA after surgery. These men were followed until the location of the recurrent cancer could be identified; 30 percent of these men developed palpable local recurrence of cancer that was confirmed by biopsy; 70 percent showed signs of distant metastases with positive bone scans.

    In this study, distant metastases were present in nearly all men who had early elevations of PSA during the first year after radical prostatectomy, men whose tumors had a high Gleason score (8 or higher), and men with cancer in the seminal vesicles or lymph nodes. Therefore, radiation therapy to the prostate bed (the area where the prostate used to be) probably isn’t going to get all the cancer in these men.

    However, men in this study who had a late rise in PSA, men with low-grade disease (Gleason 7 or lower), and men with cancer-free seminal vesicles and pelvic lymph nodes were more likely to have local recurrence of cancer— cancer that has not yet metastasized. These men, then, would be more likely to benefit from radiation therapy to the prostate bed.

    Should a man have radiation therapy immediately after surgery? No. It should be delayed at least three months, to give the body a chance to heal— and particularly to give the urinary tract a chance to recover. Irradiating a tender, sewn-together urinary tract is not the best way to encourage this inflamed tissue to heal.

    *141\201\8*

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  • Eighty-four per cent of the homosexual offenders vs. minors had nocturnal emissions, which places them sixth in rank-order, below the control and prison groups. In terms of age-specific incidence the single offenders display moderately high figures until age thirty, after which they have low percentages. The married, on the other hand, reveal variable percentages. During age-period 21-25 they rank lowest with 29 per cent, but in age-period 31-35 they rank second with 50 per cent. We doubt the validity of this sudden leap, particularly because in the following age-period (36-40) the percentage falls back to its former moderate level. As we stated earlier, the difference between the married and unmarried in incidence of nocturnal orgasm is particularly marked among homosexual offenders.

    The average (median) homosexual offender vs. minors who had nocturnal emissions had them with a frequency of 4 to 5 times a year prior to marriage. These frequencies are shared by most other offenders, but are markedly less than those of the control group. Calculating the average (mean) frequencies, however, one finds the homosexual offenders vs. minors consistently ranking third to fourth with frequencies of once to nearly twice a month—nearer, but still less, than those of the control group.

    While the offenders vs. minors parallel the homosexual offenders vs. adults in having a high percentage (71 per cent) who had homosexual dreams (the homosexual offenders rank first, second, and third in this respect), they are unlike them as far as heterosexual dreams are concerned. Some 88 per cent had heterosexual dreams, a figure that is similar to that of the homosexual offenders vs. children and far beyond the 63 per cent of the homosexual offenders vs. adults. About 3 per cent dreamed of sexual contact with animals—a small number, but sufficient to place them in fourth rank. This deserves notice only because the other homosexual offenders rank first and second in this respect.

    The proportion of total outlet afforded by nocturnal emissions is moderate for the unmarried until age thirty; thereafter the proportion increases markedly until these homosexual offenders vs. minors rank first or second from age thirty-one on. In age-periods 31-35 and 36-40 they show the same or nearly the same proportions as the control group (12-13 per cent), but in age-period 41-45 the offenders far surpass the control-group members. However, this condition is due to the high frequency of one individual; were it not for him the figures for the two groups would be more nearly equal. Among the married homosexual offenders vs. minors the proportion of total outlet constituted by nocturnal emissions is quite small (1 per cent) until age thirty, but then increases until in age-period 36-40 they rank third with 6 per cent. We have no data for them at older ages.

    In postmarital life the proportions are at first moderate but between thirty-one and thirty-five the figure increases to nearly 17 per cent—an extremely large percentage surpassing even the comparable premarital level. In the next age-period the figure falls to 11 per cent.

    The homosexual offenders vs. minors are one of the two groups who show an increase with age in the proportion of total outlet from nocturnal emissions regardless of marital status. Among the unmarried the increase is from 3 per cent in the early teens to 19 per cent in the early forties; among the married it is from 1 per cent in the early twenties to 6 per cent in the late thirties; and among the separated, divorced, and widowed, the increase is from 6 per cent in the late twenties to 17 per cent in the late thirties. At present we have no explanation for this increase.

    *185\161\2*

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  • Again like the incest offenders vs. children, a large proportion of the married incest offenders vs. minors (79 per cent, second in rank-order) had extramarital coitus. In this instance the percentage has been increased by two factors. First, these offenders are the second oldest group in our sample, the median age at reporting being forty-one years; hence they had had more time in which to have engaged in extramarital activity. Secondly, in six cases this was the offense for which they were convicted. Despite these qualifications one can still say that the incest offenders vs. minors were prone to have extramarital coitus since some groups of similar or greater age (e.g., the heterosexual offenders vs. children and the incest offenders vs. adults) do not display as high percentages, and some of the offenses for which they were convicted also constituted their extramarital experience. Their age-specific incidence figures for extramarital coitus are generally moderate insofar as such coitus is with companions: roughly one third to two fifths were thus involved between ages twenty-one to forty-five except for an unexpected 47 per cent figure in age-period 31-35, when the incest activity became chronologically possible for most of them.

    Their incidence of extramarital coitus with prostitutes is somewhat different. Beginning with moderate proportions, these offenders rise to third rank in age-period 36-40 with one fifth of them having such coitus, and remain in the same rank in the next age-period with over one quarter involved. The frequency of extramarital coitus among those with this activity is always somewhat low—a characteristic of incest offenders. However, a larger proportion of this coitus than is Usual was with prostitutes. The average individual had extramarital coitus with companions with frequencies of from 0.10 to 0.08 per week, while with prostitutes it was 0.06—a large proportion similar to that of the control group. However, the proportion of total sexual outlet constituted by extramarital coitus with either companions or prostitutes is, in general, moderate. Calculation of the average number of extramarital coital partners is confused by the fact mentioned above, that the incest in some cases constituted the extramarital coitus, but even so the incest offenders vs. minors had an average number of extramarital partners (nearly six, the same number as the incest offenders vs. adults had).

    There were too few separated, divorced, and widowed individuals to permit calculation of postmarital statistics.

    *143\161\2*

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  • The aggressors vs. minors seem to consist chiefly of two varieties. First are the amoral delinquents whom we have discussed earlier-persons who function with little regard for the controls imposed by society and who have either no conscience or an unconventional one. In psychoanalytic terms, their superegos are poorly developed. The large proportion (over one third) of amoral delinquents among the aggressors vs. minors is reflected in their extensive nonsexual criminality; the aggressors vs. minors are one of the most criminal of any of the comparative groups.

    An extreme but classic case, in that all the elements characteristic of amoral delinquents are present in clear form, is one of a man who was twenty-six at the time we interviewed him. He had no mental or physical defects and was, if anything, more alert and intelligent than the average. He had been reared variously by relatives and foster parents; his mother was an alcoholic prostitute. With this inauspicious start in life, he seems to have operated on the basis of doing or getting what he wanted without consideration for others or for consequences. This philosophy resulted in his spending the bulk of his postpubertal life in prisons. He lived chiefly by theft, supplementing this with some money from both heterosexual and homosexual prostitution. Earlier in life he had also had a substantial amount of sexual activity with a variety of animals. He belonged to gangs of the leatherjacket-switchblade sort. He drank in moderation and had experimented with drugs, just escaping real addiction. When his desires were opposed by others, or when he was angered or fearful, he used a knife. While his assertion that he had murdered may be exaggerated, he was known to have stabbed persons both in and out of prison, and once attacked a prison guard with scissors. He had had coitus with a large number of females, including his mother, an aunt, and a cousin, and homosexual activity with a larger number of males. With this description in mind, it is not surprising to learn that he had forced coitus upon a number of females, including several who fit our category of minors, and rape was his favorite masturbation fantasy.

    The second commonest variety of aggressors vs. minors (constituting between one quarter and one third) is one that is closest to the subculture offender described under offenders vs. minors, but which also often shares some elements of the amoral delinquent. This is the double-standard variety. One might describe males of this sort as looking upon young postpuberal girls as fair game if they allow themselves to be picked up or if they give other evidence of laxity, and feeling that the use of moderate force is justified if a female attempts to renege on an implied promise. These are males who would not seize upon strangers, nor would they brandish weapons, but they will wrestle with and slap their dates or girls they have picked up. Their backgrounds are more stable and conventional than those of the amoral delinquents, and they are much less criminal. Two illustrative cases follow.

    The first is an eighteen-year-old grammar school graduate who supported himself with semiskilled work. He had had a modest amount of both heterosexual and homosexual experience, the latter being in part situational due to naval service. He had no criminal record nor any other antisocial history. The only ominous note in his preoffense history was his discharge from the Navy because he could not, or would not, take orders in a reasonable manner. Subsequently, he met a young girl in a movie, arranged a date with her, and took her for an automobile ride. He attempted to obtain coitus and during the ensuing argument became angry and mistreated the girl, evidently mainly by slapping her. This led to his conviction of assault and battery with intent to commit a felony, a conviction earning him 60 days and a small fine. This sort of behavior is actually not uncommon, but only rarely does it result in legal action.

    A somewhat more violent and confused case is one of a man of twenty-one who, with three male friends, picked up six young girls hanging around a bar and cafe because the friend who was to have taken them home had broken the axle of his car. The males described the girls as “tramps” and decided they would willingly provide coitus. The whole group drove to an orchard where they continued drinking and began petting. One couple got in an argument and eventually a fight, whereupon four of the girls became frightened and departed on foot. The remaining two girls were either prevented from leaving or persuaded to stay, but in any event they were subsequently slapped around enough to produce a swollen lip on one girl and a swollen nose and eye on the other. One girl was thus forced into coitus, but the other was able to prevent penetration. The man whom we interviewed came from a conventional middle- to lower-middle-class background, his sexual life (wholly heterosexual) was not unusual, and he had been a rather active member of a Pentecostal religious sect. The psychologist described him as “. . . fairly alert and intelligent … a socially gauche person who has little understanding of the nature of ordinary interpersonal and heterosexual relationships.” The offender, while admitting his behavior conflicted with his religious principles, rationalized his going out with the young girls by saying “. . . everyone was going out with girls under eighteen, so why not me?” and excused the force by labeling the girls as “tramps” and “teasers.”

    Aside from these two varieties the remaining aggressors vs. minors in our sample do not lend themselves to categorization. Definite pedophilia seems involved in only two or three cases. Mental defect does not seem an important factor in more than one instance, and no senile deteriorates were in the sample. Sociosexual underdevelopment such as we saw among the offenders vs. children is suggested in but one case. Only two or three cases show definite psychotic manifestations, but this is to be expected since the majority of the unmistakably insane were confined in institutions where we did no interviewing. The combination of mental defect, psychoneurosis, and alcohol, which was so evident among the aggressors vs. children, seems unimportant among the aggressors vs. minors.

    *101\161\2*

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  • On the whole, the offenders vs. minors were a healthy group, and had had an excellent relationship with their parents. Their prepubescent life, which was protracted by a high percentage who reached puberty late, contained little sexual activity.

    Adult life was marked by a great emphasis upon heterosexual activity; masturbation and nocturnal orgasms were unimportant, and homosexual activity was moderate to low in quantity. In their heterosexuality, they lean toward simple direct behavior; mouth-genital contact, variation in coital positions, etc., they seem to regard as unnecessary frills. This tendency toward simplicity is again seen in the small amount of dream content and masturbation fantasy; these men are rather unimaginative. Seeing or thinking of females or seeing erotica arouses little response in them. Neither mental troubles nor alcoholism can be said to have complicated their lives, but they are one of the intellectually dullest groups.

    For a large percentage, the sex offense represented their first and only conviction, and relatively few were convicted on a sex charge a second time. Their nonsexual criminality, while substantial, consisted chiefly of property offenses of a moderate to almost trivial nature. These men are neither professional criminals nor amateurs given to armed robbery or violence.

    Two thirds of their offenses vs. minors came to light chiefly through friends or relatives of the girls involved or as a by-product of police investigations of other matters. Only rarely did the girl herself make a complaint to the authorities.

    All in all, these offenders appear to be uneducated, somewhat simple-minded males in a low socioeconomic bracket; while not basically criminal, they are free and easy with other people’s property and not particular about their female sexual partners. It is interesting that they stressed gambling more than any other sex-offender group. They try to satisfy their desires in a simple immediate way, which usually consists of taking what they want regardless of circumstance.

    This description also fits the offenders vs. adults. Indeed, the two groups constitute a whole consisting of males in a lower socioeconomic stratum who differ from their control-group brothers in being less responsible and more given to immediate gratification with little thought of possible social complications. One might with justification say that the backgrounds and behavior of the offenders vs. minors and adults are essentially the same and that it was almost fortuitous whether their convictions were for sexual activity with girls twelve to fifteen or sixteen and older.

    On the other hand, one cannot regard the offenders vs. minors as entirely would-be offenders vs. adults who were either a bit too careless regarding age or who were simply the victims of statistical probability. The group contains a number of men who have some sexual interest in very young females. These are visible when one studies the multiple sex offenses: of those men with over one, more had been convicted of offenses vs. children than offenses vs. adults. The reason seems to be that the usual offender vs. minors or adults “learns his lesson”—he confines his subsequent sexual activity to suitable older females or at least exercises more care in his affairs. In any case, he is seldom convicted again. The pedophile variety of offender, on the contrary, finds it difficult to make a satisfactory upward shift in the age of his female partners, and since he continues to single out children under twelve he is more likely to undergo a second arrest and conviction.

    If one were to weed out those with pedophilic tendencies and a few others who were mentally seriously defective, the remaining majority of offenders vs. minors would scarcely merit the emotionally charged label of sex offender. The near-peer variety constitutes a moral issue rather than a legal problem; and the subculture variety could be dealt with at the level of warnings and misdemeanor convictions. We shall always have with us our quota of well-intentioned extroverts who are not very bright, and we do no one a service by branding their errors of judgment as felonies.

    *59\161\2*

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  • Before taking up the vital statistics common to all groups, such as age, education, and marital status, it is expedient to examine; the sex offenders and prison-group members in terms of type of offense and number of offenses.

    The 888 men in the prison group accounted for 3,069 offenses, or roughly three and one-half offenses per man. About half of these were misdemeanors for which a sentence was served; 14 per cent did not result in imprisonment, but in a fine, probation, or suspended sentences; and a third were felonies for which a sentence was served. The penologist will find nothing unusual in the proportions of general types of offenses: 48 per cent were crimes against property, chiefly stealing; 20 per cent were vagrancy or disorderly conduct, charges usually connected with drunkenness; 16 per cent were crimes against the public: order, such as gambling and use or sale of narcotics; 10 per cent were crimes against person, such as assault and battery, homicide, and armed robbery; 1 per cent were what we call “sex-connected” offenses such as bigamy, bastardy, and pimping, and the remaining 4 per cent of the offenses could not be clearly identified.

    The total sex-offender group has been subdivided according to the type of behavior that constituted the offense. Since a man can be convicted of several different types of offenses he can correspondingly appear in an equal number of sex-offense groups. For example, one man can be counted as a rapist and also as a peeper. Consequently, the sum of the individuals comprising the various sex-offender groups exceeds 1,356—the actual number of white male sex offenders used in this study. While we shall deal with a score of sex-offender groups, we shall be primarily concerned with 14 that are well-defined and that contain at least 25 individuals each.

    *16\161\2*

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