The purpose of this chapter is to alert the doctor to the way unconscious conflicts, ambivalence and covert problems can present under the guise of a problem with contraception. It may well be inevitable, and indeed necessary, for the doctor to be caught up to some extent in the patient’s conflict in order for it to be understood. Provided he or she can then step back and think about what is going on and suggest an interpretation for the patient, it may be possible for the conflict to be resolved.

*2/197/1*

National governments too are involved in individual decisions about fertility. Although there are 75 countries in which the birth rate is considered to be too high, there are still 21 where there are national policies aimed at increasing the number of births (United Nations, 1990).

*3/197/1*

The change in symptoms and improvement in urinary flow with alpha blockers isn’t as dramatic as it is after prostatectomy, and alpha blockers aren’t recommended for men with severe symptoms. On the other hand, alpha blockers create fewer side effects than prostatectomy—and they’re all reversible when men stop taking the drug. One advantage of alpha blockers is that they work almost immediately, unlike finasteride, which must be taken for months before any change is noticeable. A drawback is that alpha blockers don’t change the course of BPH—they work like cold pills, just treating the symptoms, not the underlying cause of the illness. If your doctor prescribes an alpha blocker, you’ll probably be checked regularly over the first few weeks to fine-tune the dosage of the drug. Then you should be seen every few months to have your prescription refilled and your symptoms checked.

Side Effects. Alpha blockers improve urine flow by relaxing clenched smooth muscle tissue. Because their effect is not limited simply to the prostate, they may not be best for men with a history of significant heart disease or blood pressure problems. But they don’t seem to have any adverse effects on blood pressure or heart rate in men who are otherwise healthy. They are vasodilators —they open up blood vessels, making a wider channel for blood to go through, which means they reduce blood pressure. Their side effects can include dizziness, heart palpitations, lightheadedness or even fainting, nasal congestion, and fatigue, especially during the first few doses. These symptoms tend to improve over time as the body adjusts to the drug. They also seem to be diminished in men who take the drug at night.

*287\201\8*

Another important point to discuss with your doctor: About 15 percent of men who undergo open prostatectomy need a blood transfusion during the procedure. The best blood for you to receive is your own; if your hospital allows this, it’s a good idea to donate several units of your blood ahead of time.

Shortly before surgery, your doctor may want to get a baseline evaluation of your upper urinary tract to spot anything out of the ordinary. One way of doing this is with ultrasound, which can help detect hydronephrosis (distention of the ureters and renal pelvis, caused by an obstruction downstream) and pick up any unusual masses in the kidneys. This painless, noninvasive technique will also give doctors a pretty good indication of the size of your prostate and the state of your bladder—whether there’s any residual urine there. And at the time of surgery, your doctor will probably use a cystoscope—a lighted tube, inserted into the tip of the anesthetized penis—to check for any other surprises in the bladder, such as a stone or tumor that needs to be removed.

*248\201\8*

When sexual function is normal, this is what happens: A man becomes sexually aroused. A substance called nitric oxide is released by the nerve endings, and the smooth muscle tissue in the penis begins to relax. The spongy chambers (also called sinusoids) within this smooth muscle tissue begin to dilate. Meanwhile, arteries continue to pump blood, as usual, into these spongy chambers of the penis. As the penis elongates, the veins are stretched; they clamp down against the thick tissue that surrounds the corpora cavernosa —shutting themselves off so the blood can’t leave the penis. The chambers become engorged, and this keeps the penis “inflated” during sexual activity. An erection is born.

After ejaculation, nitric oxide stops being released; the smooth muscle tissue contracts and the blood flow to the penis is reduced—the veins ease their viselike grip. Once again, blood is allowed to leave the penis, and the erection goes away.

*209\201\8*

Castration is irreversible, and for many men, this is too final a treatment. In one 1989 survey, only 22 percent of prostate cancer patients opted for surgical castration; 78 percent of these men chose alternative hormonal therapy (they picked LHRH analogs, discussed in this chapter).

Testosterone is the hormone that makes men feel “manly.” When it is missing, some of the characteristics associated with being male vanish along with it. Side effects of castration—surgical or medical—can include tenderness, pain or swelling of the breasts (this is called gynecomastia), and loss of sex drive. Impotence is not an absolute certainty; 10 percent of men do remain potent. However, they are rare exceptions to the rule. (Impotence here, unlike impotence in other situations, means loss of libido as well as the ability to achieve an erection.)

*172\201\8*

Other studies of radiation therapy use different measuring slicks—prostate biopsies and PSA tests. Depending on how many biopsies are taken, anywhere from 30 percent to 90 percent of men who have received external-beam radiation therapy can have a positive biopsy two years or more after treatment. Although this does not mean that allot these men will have treatment failure— that their cancer will come back—long-term follow-up studies have found that many patients do. At five years after treatment, only 25 percent of patients will have low or undetectable levels of PSA. At ten years, only 10 percent will. However, despite the fact that PSA may be measurable, many of these men have not yet demonstrated any clinical signs of treatment failure (urinary tract obstruction, for example); these findings suggest that radiation therapy can effectively control local symptoms from prostate cancer in many patients. And frankly, for many older men—a 75-year-old man who gets radiation today, for example—it isn’t going to matter too much if PSA rises slightly ten years from now, if the therapy has controlled the cancer.

*134\201\8*

There is nothing unusual about the rapidity with which these men acquired their convictions as adults. About one quarter had been convicted of some crime by age eighteen, one third by age twenty, one half by twenty-three, and three quarters by thirty. This record lags behind that of the prison group. However, in convictions resulting in imprisonment for a year or more, essentially felony convictions, these offenders catch up with the prison group by age thirty and subsequently surpass it. This is because of their sex offenses, which are chiefly felonies; they have a higher per capita felony conviction than the members of the prison group.

The average (median) age of the homosexual offender vs. children when first convicted for any offense was twenty-four—a moderate age. His first conviction for a homosexual offense against a child came when he was thirty, the same age as the homosexual offenders vs. minors.

The ratio of sex-offense to nonsex-offense convictions, 53 per cent vs. 47 per cent, is in no way unusual and is quite similar to that of the homosexual offenders vs. adults and several other groups. Nor is the proportion of “pure” sex offenders, 54 per cent, remarkable.

The number of convictions per capita is large—4.03, a figure exceeded only by the aggressors vs. children and by the two notorious “repeaters,” the peepers and exhibitionists. However, the size of this figure is not due to sex offenses (the 2.15 per capita sex-offense figure is moderate) but to predilection for vagrancy-disorderly conduct convictions, in which they rank second with nearly one apiece. Indeed, these account for nearly half of their nonsex offenses, the largest proportion of any group. The other types of crime were correspondingly unimportant in terms of percentages, and offenses against the person were quite infrequent.

Examining now the sex offenses other than those against male children, we find that the homosexual offender vs. children favored male minors (52 per cent), to a lesser degree male adults (16 per cent), and to a still lesser degree females (14 per cent). Other sex offenses were numerically unimportant. In brief, these men were rather specialized in their sex offenses; 87 per cent of them were homosexual offenses.

Their recidivism rate was moderate, slightly higher than the prison group’s.

*178\161\2*

The incest offender vs. minors differs from the incest offender vs. children in having been exposed to a sexual temptation more understandable to the average man; for unlike a child, girls from twelve to fifteen are often close to physical maturity and in the eyes of many are on the threshold of sexual acceptability. In brief, the hypothetical average man would be inclined to regard the incest offender vs. minors as entitled to some, albeit small, sympathy—especially if the girl were a stepdaughter rather than a genetic daughter.

In their own defense, the incest offenders vs. minors are especially prone to emphasize the physical maturity of their daughters. Like offenders vs. children and aggressors vs. children, they may occasionally add a year or two to the girl’s age. In view of the crushing disapprobation directed against offenders vs. minors, their attempt to minimize their offense is quite understandable. Another mitigation not infrequently claimed is that the daughter instigated or appeared receptive to the sexual contacts; this will be analyzed subsequently in detail.

*136\161\2*