Which BPH treatment is right for you? With all of them—even watchful waiting—there’s a risk of complications. Be your own advocate; learn as much as you can. Before committing to one of these treatments, you owe it to yourself to find answers to some basic questions, including: What are the odds that my symptoms will improve?

*How long will the effects of the treatment last—will I need to do this again? *What are the risks of complications, and which complications are likely to result?

Symptom Improvement. The top row of table 10.3 shows your best odds for symptom improvement lie in the TURprocedure. But even the TURis not an ironclad guarantee; the ranges for all of these are pretty wide. One surgical rule of thumb: Generally, the worse your symptoms before treatment, the more dramatic the improvement—if the treatment works.

Incontinence. As the third row of table 10.3 indicates, over the short run, the risk of uncontrollable urine leakage is extremely rare, even with surgery.

However, over time, BPH itself can cause incontinence; that’s one long-term risk of watchful waiting. And men taking alpha blockers or finasteride may run some risk of incontinence over the long run.

Impotence. Discussed in the table.

Need for Future Treatment. The ranges indicated in the fifth row of table 10.3 are so wide because doctors really don’t know the long-term success of some treatments. Some men who opt for nonsurgical treatment wind up getting surgery later to relieve bothersome symptoms. And some men who do get surgery may need it again after several years if the prostate grows back.

Loss of Work and Activity Time. The sixth row of the table includes time spent at the doctor’s office and in the hospital.

*293\201\8*

Similar to the suprapubic operation in terms of anesthesia and recovery, the retropubic approach is preferred by many surgeons because it allows better access to the prostate and a more accurate approach to the urethra.

What Happens

In retropubic prostatectomy, surgeons go directly through the top of the prostate, rather than through the bladder—first making an incision in the lower abdomen, and then separating the abdominal muscles. Instead of opening the bladder, the surgeon moves it aside, and there, beneath the pubic bone, is the prostate.

A small incision is made in the outer capsule of the prostate, and (as in suprapubic prostatectomy) the surgeon’s index finger is inserted to remove the overgrowth of prostate tissue compressing the urethra. To avoid the development of epididymitis, many surgeons go ahead and perform a vasectomy during this procedure. The prostate tissue removed during surgery is then sent to a pathologist for examination.

*254\201\8*

Early on, however, erections are not sufficient for traditional vaginal penetration. One common reason for this is the venous leak—even though the arteries are doing their job and filling the penis with blood, producing a partial erection, the veins aren’t keeping the blood trapped inside the penis. To improve this situation, many men find that if they attempt sexual activity standing up, they’ll be able to achieve a much firmer erection. (The blood has to travel all the way back up to the heart, and this takes longer if a man is standing up than if he’s lying down.) Sexual activity can continue either while a man remains standing, or while he’s kneeling. Also, it may help to attempt entry from behind; the vagina opens more easily if a woman is bending forward.

Another way to combat venous leak is for men to place a soft tourniquet at the base of the penis before they begin foreplay or sexual stimulation. The purpose of the tourniquet is to keep blood in the penis, once the stimulation causes the arteries to dilate and penile blood flow to increase. The tourniquet doesn’t impede blood flow into the penis; it just keeps it from going back out. (A material called Coban works well for many patients. This is a transparent tape that can be cut into strips one-half inch to three-quarters of an inch wide. It does not stick to hair, and it can be bought in most drugstores.)

The return of sexual potency has a lot to do with the patient’s age and stage of the tumor. For some men, it can take as long as four years for full potency to return. For others, intercourse is possible just a few weeks after surgery. In any case, you don’t have to wait for the penis to become erect on its own. If you are not having erections yet, you may wish to try a vacuum erection device (see below).

Finally, it’s worth repeating that almost all men who can’t obtain an erection after radical prostatectomy still have normal penile sensation and are able to achieve a normal orgasm. Therefore, even if your body can’t produce an erection, it will still be possible for you to restore sexual function. There are three basic approaches, discussed below.

*217\201\8*

LHRH agonists shut down production of LH and FSH. Here’s how they work: LHRH is a small protein, built of ten blocks of amino acid. A synthetic substance called an LHRH-analog, or agonist, made by changing one of the ten blocks, works by inhibiting LH (the hormone that tells the pituitary gland to make testosterone). The hypothalamus acts like a lighthouse, sending out LHRH in signal pulses—like Morse code in flashes of light—to the pituitary gland. LHRH agonists work by providing prolonged signals—by turning on the light and keeping it on, instead of just sending flashes. So these drugs trick the pituitary; because the pituitary receives no flashes, or pulses, it thinks no signal is being sent—and it doesn’t make LH.

These drugs don’t work right away. In fact, for about a week after a man begins taking an LHRH agonist, his testosterone level kicks into overdrive. This is called a “flare,” and it happens because the constant LHRH signal initially stimulates LH production. But by about ten days, testosterone falls into the castrate range. For the first few weeks, doctors often prescribe another drug, such as flutamide, to block this surge.

The most commonly prescribed LHRH agonists are leuprolide (Lupron) and goserelin (Zoladex). In large studies, researchers have found that these LHRH agonists are equivalent to treatment with DES or surgical castration in their ability to lengthen the time until the cancer progresses, and to prolong survival. These drugs are given in monthly injections.

To sum up: LHRH agonists are basically equivalent in testosterone-lowering and lifespan-lengthening results to DES, which is basically equivalent to surgical castration.

The chief advantages of LHRH agonists are that they avoid the need for surgery, and that they don’t cause breast swelling as often as treatment with estrogen. Also, they don’t have the risk of cardiovascular complications that can accompany estrogen treatment.

Side Effects. Like surgical castration, however, LHRH agonist treatment does cause hot flashes, loss of sex drive, and impotence. Other disadvantages include the need to get monthly shots, and the tremendous expense—LHRH agonists cost hundreds of dollars a month.

*178\201\8*

As a general rule, men with organ-confined cancer or men with cancer that has penetrated the prostate but still was removed in its entirety (men who had “negative surgical margins”) and Gleason scores of 6 or less should not receive radiation therapy after radical prostatectomy.

The best candidates for radiation after radical prostatectomy are men who have positive surgical margins—but cancer that has not yet reached the pelvic lymph nodes and seminal vesicles. However, even this is not a crystal-clear decision; not all of these men are going to need radiation. For many of these men, the radical prostatectomy will be enough to control the cancer. One option is for men to have regular PSA tests and begin radiation treatment only if the PSA starts going up.

And there’s yet another consideration: Not all of these men with rising PSAs are going to be helped by the radiation, because of the problem with distant metastases we mentioned above. So what you and your doctor need to determine is, why is the PSA going up? Is it local recurrence of cancer, or the presentation of distant metastases?

*140\201\8*

As we mentioned previously, masturbation was relatively a more important sexual outlet to the homosexual offenders vs. minors and adults than to other offenders or control-group individuals. This fact is illustrated in age-specific incidence: in virtually any age-period after puberty the single homosexual offenders vs. minors and homosexual offenders vs. adults may be found in the top three ranks with 88 to 100 per cent of their members involved. In early life when masturbation is prevalent among all groups this phenomenon is less clear-cut, but in later life the differences are more dramatic. For example, among the single males between the ages of thirty-one and thirty-five about 67 per cent of the control group and 46 per cent of the prison group masturbated, whereas 100 per cent of the homosexual offenders vs. minors and 89 per cent of the homosexual offenders vs. adults did so. A group whose preferred sociosexual activity is taboo can be expected to have a high compensatory incidence of masturbation, but this cannot wholly account for the differences—especially since many homosexual offenders vs. children were not predominantly homosexual in their interests. This is illustrated in the age-specific incidence of masturbation among married homosexual offenders vs. minors. Aside from a high (55 per cent) incidence between ages twenty-one to twenty-five, the incidence of masturbation is not unusual and is within five percentage points of that of the control group. The same phenomenon may be seen in accumulative incidence, the proportion with postpubertal masturbation by a given age. By age twelve the number of homosexual offenders vs. minors with such experience is exceeded by none. At later ages, as one would expect, the differences in this ever-never type of measurement become progressively less.

In frequency of premarital masturbation the homosexual offenders vs. minors rank second only to the homosexual offenders vs. adults. The average (median) individual occupies second rank in three out of five age-periods having a frequency of from roughly twice a week to once a week. These frequencies are nearly double those of the control group. The picture presented by the average (mean) frequencies is similar: the homosexual offenders vs. minors ordinarily occupy second or third rank with frequencies of from 2 to 3 a week. Despite the high ranking of the unmarried homosexual offenders vs. minors, the married individuals show only moderate masturbation frequencies.

The unmarried males obtained only a moderate proportion of their orgasms from masturbation until age-period 26-30 when they rank third with 46 per cent of their orgasms thus derived. From then on they rank first or second. One might speculate that as they aged and the awkward age gap between themselves and their minor objects widened, they increasingly turned to self-stimulation, but actually the percentages of total outlet from masturbation remain rather stable (45-49 per cent) between ages twenty-one and forty, though always exceeding the percentages derived from homosexual activity. The married men, not so homosexually inclined, relied less on masturbation and have ordinarily moderate to small proportions (1-7 per cent). It is noteworthy that these offenders, single or married, display smaller masturbatory proportions of total outlet than the homosexual offenders vs. children. This may well reflect the difference between the sexual accessibility of children and of minors, more of the latter having budding sexual drives of their own.

Among males whose marriages ended, masturbation never again equaled its premarital importance (in proportional terms), but did rebound to a greater degree than in either the control or prison groups.

This emphasis on masturbation is again seen in the study of the maximum frequency of masturbation achieved in any one week. Some 15 per cent of the homosexual offenders vs. minors had masturbated more than 12 times in one week, a percentage exceeded only by the peepers and the homosexual offenders vs. adults. Conversely, a relatively low percentage (14 per cent) had their maxima as once or twice a week. The average was 6.4 a week, the third highest recorded.

There is nothing unusual about the masturbatory fantasies of the homosexual offenders vs. minors except, naturally, that a much larger percentage (78 per cent) than usual had had homosexual fantasies and fewer had heterosexual fantasies. The homosexual offenders rank first, second (the offenders vs. minors), and third in the proportion who had fantasies of males while masturbating. They rank in the same sequence in erotic response to thinking of or seeing males: some 73 per cent of the homosexual offenders vs. minors were sexually aroused by such stimuli, and 43 per cent reported strong arousal. Only the homosexual offenders vs. adults reveal larger proportions.

The homosexual offenders vs. minors are in no way unusual in the amount of concern they suffered regarding the alleged bad effects of masturbation.

Like other homosexual offenders, a relatively large proportion of the offenders vs. minors learned of masturbation through being masturbated by someone else (36 per cent, third in rank-order) and through self-discovery (16 per cent, fifth in rank-order). Few (27 per cent, the third smallest proportion) learned from observation. As explained earlier in the discussion of homosexual offenders vs. children, the high figure for being masturbated stems from the large amount of prepubertal sex play, most of which was homosexual. The high figure for self-discovery is the result of the large number who masturbated, not only before puberty but at a quite early age when self-discovery is more probable.

*184\161\2*

The average (median) incest offender vs. minors was twenty-two years old at his first marriage. A year later, by age twenty-three, some 79 per cent were married, and by age thirty, 98 per cent. Because of this, plus their greater average age, these offenders had spent a greater proportion of their postpubertal years of life as husbands (58 per cent) than anyone else.

This drive toward matrimony does not mean that their marriages were notably stable; in fact, a relatively small number (53 per cent) stayed with their first wives and a large number (21 per cent) had three or more marriages. On the other hand, these offenders do not show a tendency toward brief marriages such as was seen among the aggressors vs. minors; a relatively small number reported marriages that terminated within two years.

The incest offenders vs. minors were likewise not given to hasty marriages, but knew their future wives for a comparatively long time before marriage—nine months, to be precise. While this figure is far less than the control group’s 17 months, it is surpassed by only two groups besides the control.

Despite this relatively lengthy acquaintance only a moderate number had premarital coitus with their subsequent wives. Notwithstanding this, and in the face of the rather low frequencies of premarital coitus in general (we did not calculate frequency with fianc?e alone), an inexplicably large proportion of premarital pregnancies resulted: 27 per cent, the largest number recorded, of the brides were pregnant as they took their vows.

In later life they lived up to this omen of fertility; the average couple produced nearly five children, making the incest offenders vs. minors our second most fertile group, the first being the incest offenders vs. adults, and the third the incest offenders vs. children.

There is nothing unusual about the amount of time spent in precoital play or in the sexual techniques of the incest offenders vs. minors. The only point worth noting is that a large number of this group, like the incest offenders vs. children, had used coital positions other than the standard male-prone female-supine.

The incest offenders vs. minors display low to intermediate frequencies of marital coitus. While their position in the rank-orders thus varies, the actual median frequencies remain surprisingly uniform: for example, in age-period 16-20 the average individual had coitus with his wife 2.17 times per week; in age-period 21-25, 2.38; in age-period 26-30, 2.32; and in age-period 31-35 the frequency is back to 2.16 per week. These frequencies are lower than those of the control group. It may be recalled that these offenders vs. minors also displayed low frequencies of premarital coitus.

The mean frequencies are nearly always low and never higher than intermediate in rank-order.

Despite the low frequencies of marital coitus, this particular sexual activity constituted both an absolutely and relatively large proportion of the total sexual outlet of these married offenders in their teens and twenties. From age sixteen to thirty they drew 90 to 94 per cent of their total outlet from this source, proportions earning them first or second place in the rank-orders; in age-periods 21-25 and 26-30 they were second only to the incest offenders vs. adults.

The wives of the incest offenders vs. minors seem to have had orgasms less often than the wives of the men in other groups, if one can believe their husbands’ reports. A somewhat large number (18 per cent, fourth in rank) of their wives’ married years were marked by low (10 per cent or less) orgasm rates, while a somewhat low percentage (53 per cent) were accompanied by high rates (90 per cent plus). This picture may reflect the equally mediocre marital happiness ratings described below rather than any specifically sexual maladjustment.

Few incest offenders vs. minors reported many years of happy marriage (26 per cent, third smallest proportion) whereas 20 per cent, the second largest proportion of years, were very unhappy.2 The largest number of years, in absolute terms, were rated as moderately happy—a category wherein they rank third with 36 per cent, while the incest offenders vs. children rank second.

*142\161\2*

The average aggressor vs. minors was slightly over twenty-three at the time of the offense, a full year and one half younger than his

counterpart, the offender vs. minors, a year younger than the average aggressor vs. adults, and eight years younger than the aggressor vs. children. The aggressors vs. minors are the youngest of the comparative groups of sex offenders, not only in terms of age at offense, but of age at interview. Why this should be is not altogether clear. However, among the heterosexual offenders and aggressors (excluding the incest offenders, naturally) one uniformly finds the oldest are those whose sexual objects were children, next oldest those whose objects were adults, and youngest those whose objects were minors. More of an explanation lies in the general criminality of the aggressors vs. minors. Nearly a third had at one time or another gained a substantial portion of their livelihood from some sort of illegal activity; no other groups come close to matching this figure except the prison group (26 per cent) and the aggressors vs. children (24 per cent). One may describe the aggressors vs. minors as young males headed for trouble at an early age, and victimizing young girls can be regarded as a natural offense for antisocial, aggressive young men.

About one quarter of the aggressors vs. minors were married at the time of offense, nearly one fifth had previously been married, and slightly more than half had never married.

As one would anticipate in a young group, a large percentage (62 per cent) of the offenses represented the individual’s first sex offense. For a substantial number (nearly one third) this conviction was their second sex offense.

Neuroses and psychoses were insignificant in this group; only two individuals had experienced serious mental difficulty.

Alcohol, which plays such a role among other aggressors, was not particularly important: only one quarter were drunk at the time of the offense, half that number were mildly to moderately intoxicated, and 62 per cent were cold sober. No drugs were involved in any of the cases.

In 18 per cent of the offenses there were two or more males involved; no other group equals this figure, which is probably the result of the common tendency of young males to foray in pairs or groups. Among the offenders vs. minors or adults such gregariousness does not often result in group sexual activity since girls ordinarily wish to avoid it, and the offenders, by definition, cannot override the girl’s wishes with force or duress.

The concept of the aggressors vs. minors as irresponsible, aggressive, and somewhat antisocial young men with an eye open for a free drink, an easy dollar, or an available girl, is reinforced by the fact that between one fifth and one quarter of their offenses vs. minors were opportunistic rather than premeditated. This is by far the largest proportion of opportunistic offenses recorded. Aside from a very few non compos mentis cases, all the other offenses were premeditated.

In keeping with the elements of aggression and opportunism, the locale of the offense was chiefly outdoors (43 per cent). Residences rank second (29 per cent), and automobiles third (21 per cent). The importance of the outdoors and automobiles, shared also by the aggressors vs. adults, reflects the need to be away from other persons who might report on or interfere with their activity.

The age distribution of the victims is most interesting. Among the offenders vs. minors we saw a clear preference for older females; only 15 per cent of the girls were twelve, and the percentages increased with increased age, 40 per cent of the girls being fifteen. Among the aggressors, however, the most popular age was fourteen (36 per cent) with ages thirteen and fifteen being second (each with 25 per cent). One will recall that the aggressors vs. minors surpassed all other groups in the number who expressed a preference for girls aged sixteen to seventeen, and ranked first among those who preferred girls twelve to fifteen; acceptability always covers a wider range than preference. Also worth recollection is the fact that an unusually large percentage of the aggressors vs. minors had their first coitus with girls from twelve to thirteen. In summary, there is good reason to believe that a substantial number of the aggressors vs. minors chose their victims because of, not despite, their age.

As is usual among aggressors, the girls were preponderantly strangers (63 per cent). Acquaintances account for 22 per cent, friends for 11, and relatives for 4. Anthropologists and sociologists could scarcely ask for a better example of how violence increases with social distance.

The sexual activity constituting the basis of the offense was chiefly coitus (48 per cent) and attempted coitus (17 per cent). Petting involving touching the genitalia and petting not involving genitalia each accounted for another 10 per cent. Mouth-genital contact was the basic behavior in an additional 7 per cent. This leaves a residuum (7 per cent) of what can best be described as “general attack”—a sexually motivated assault with the intent to do physical damage.

Turning now to the behavior of the girls, we find that both the aggressors’ reports and the official records agree that in 72 per cent of the cases the girl consistently resisted. In the remaining cases the aggressors claimed the girls were either passive or encouraged the relationship, but the official records indicate resistance at least in the latter stages of the activity.

The majority of the aggressors sought cooperation from the girls—in 62 per cent of the cases they embarked upon the conventional preliminaries to seduction and resorted to force only when these efforts proved either ineffective or too time-consuming. Three fifths employed mild to moderate force. One quarter used much force; such exertion is usually unnecessary with children and young girls, but we shall subsequently see the percentage rise to 41 when adult women are the victims. Our data concerning threats are inadequate, but there is a strong suggestion that threats play a substantial part in intimidating the girls.

In about 70 per cent of the offenses the apprehension of the male depended primarily on the girl, but in nearly two fifths of the cases (a high proportion) there were other elements in the situation that made arrest probable. In the great majority of cases the girl did not directly complain to the law-enforcement authorities; the complaint was made by her relatives or friends (71 per cent).

Only half of the men fully admitted their behavior, a rather small proportion. These aggressors vs. minors were especially prone to give qualified admissions of guilt—admitting to the sexual activity, but denying the force or duress. Some 36 per cent gave; qualified admissions, by far the largest proportion recorded for any group.

*100\161\2*

The category of offenders vs. minors was established for two purposes: to separate more sharply the offenders vs. adults from the offenders vs. children, and to test the idea that there is a discrete “type” of male sexually preferring females at or just past the age of menarche.

Being an intermediate buffer group, the offenders vs. minors are motley. Perhaps as many as one fifth of them appear indistinguishable from the offenders vs. children: we see again the pedophiles, mental defectives, senile deteriorates, and drunks. Indeed, around 8 per cent of the offenders vs. minors were also convicted of offenses vs. children. On the other hand, certain varieties seen among the offenders vs. children are rarer among the offenders vs. minors: the psychotics and the cases of underdeveloped sociosexuality dwindle to the near vanishing point.

The great bulk of the offenders vs. minors may be conveniently classified into two varieties: subculture offenders and near-peer offenders.

The subculture offenders are those who belong to a portion of society, a subculture, which regards as a suitable sexual object any female past menarche, or even a prepubescent female if she is of adult size. In envisioning such a subculture one at first thinks of the rural mountain people, but this same low age limit may be found among the lower socioeconomic stratum in big cities. The existence of this subculture is clearly indicated in a tabulation of the ages of the wives of offenders vs. minors at the time of marriage. In cases of multiple marriage, the youngest wife was chosen. In the tabulation there is a bimodal distribution of cases: 25 per cent of the wives were twenty-one years old or older, rather few were twenty (5 per cent) or nineteen (10 per cent), but 17 per cent were eighteen, 19 per cent seventeen, and 15 per cent sixteen. In other words, half of the brides were aged sixteen to eighteen; about a tenth were younger. It is obvious that a man who married, say, a sixteen- or seventeen-year-old is not going to regard a fourteen- or fifteen-year-old as too young for a sexual relationship.

Among the offenders vs. children we differentiated amoral delinquents and situational cases; both of these tend to blend in with the subculture offenders when one examines offenders vs. minors. In the absence of questions and answers designed specifically to distinguish between varieties of offenders, it is hard to make a distinction between a man who has coitus with a minor because he thinks it a licit normal act and a man who is permanently or temporarily indifferent to the age of his coital partner.

A typical example of a subculture offender is a thirty-four-year-old man who had lived most of his life in Kentucky. His premarital coitus was with partners of rather widely diverse ages; in fact his first coitus, at age thirteen, was with a woman of thirty, and it is significant that he, rather than she, made the initial overtures. At nineteen he married a girl aged sixteen. The marriage was a happy one, but she died after ten years leaving him at twenty-nine a widower with two children. His postmarital life seems to have been similar to his premarital life, and by age thirty-three he was regularly dating a girl of fifteen, nearly the same age as his daughter. After three months, during which coitus was a regular occurrence, the girl’s father made the complaint that resulted in the man’s arrest and conviction. The prison psychologist’s remarks are worth quoting: “[He] cannot see that any illegality was involved. . . . The subject leads a casual life. . . . He found a mutually pleasing relationship involving few objections so he made the most of it. He is not criminally aggressive nor does he thrust himself forward where his attentions are unwanted.”

The near-peer offenders are simply males who are so close in age to their “victims” that a sexual relationship is psychologically and socially appropriate although illegal. A classic case is that of a seventeen-year-old boy and a fifteen-year-old girl. In prison, where the boy was serving six months for statutory rape, the psychologist described him as “… an embarrassed male of seventeen who had intercourse with a girl fifteen. He says she offered no protest and he thought there would be no legal complications. He has had intercourse with girls of the community for a matter of two years and saw no reason why it should not be continued. . . . [His] social group fully approves of such a pastime procedure. Much fault seems to rest in the willingness of the girls. . . .”

In some instances the age difference may seemingly be large enough to bar a person from the near-peer group—say a difference of six years. However, if the male is socially (and usually mentally) retarded while the female is precocious, he may still be classed as a near-peer case. A backward twenty-year-old who tends to associate with persons in their late teens is not far removed socially from a precocious fourteen-year-old girl who also associates chiefly with those in their late teens. Indeed, in urban juvenile gangs the gang (peer group) often has an age-range of fourteen to twenty. A liaison between an older gang leader of twenty and a “deb” of fourteen would be considered as a mating of peers.

*58\161\2*

Our control group was obtained primarily through a sampling technique described in our previous volumes. We selected a well-defined social or professional group and attempted to interview every member. Realizing the danger of selectivity in sampling on a voluntary basis, we worked with each chosen group, returning again and again, if necessary, until we had interviewed at least half (and usually nearer three quarters) of its members. We do not stop when we have interviewed those who came to us freely or with little prompting; we continue with what at times must be annoying persistence, obtaining the case histories of persons who come to us as a result of the pressure exerted by other group members, their conscience, and our polite harassment. Once we have the opportunity to talk with these reluctant and hence especially valuable individuals, they almost always become quite cooperative and ascribe their previous foot-dragging to their ignorance of our methods and attitudes. Approximately one third of the control-group individuals derive from groups wherein we interviewed 90 to 100 per cent of the constituent members.

Dr. Alfred C. Kinsey, who began and directed this research until his death in 1956, was never impressed by the desirability of keeping a record of refusal rates—the proportion of those who were asked for an interview but who refused. He felt that an individual should not be considered a refusal until he or she had been the recipient of Dr. Kinsey’s persuasiveness, which was extraordinary. However, throughout most of the history of the research, and particularly in the earlier years, the interviewers were frequently in a position which made the recording of refusals almost meaningless; when beginning with a new group of subjects it is imperative to interview as large a number as possible in as short a time as possible so that there will be a sizable proportion of the group that can report favorably on the experience and influence others to contribute their histories. To use a military analogy, once a breakthrough has been achieved there must be no delay in pressing onward. This means that one must take first those who are most willing to be interviewed. Afterward one can afford to return to those who originally were reluctant and spend a considerable amount of time on a second or even third solicitation.

Let us say, for example, that we have been working with a large group, one too large to interview in its entirety. We have interviewed 50 per cent of the members; we feel that we have sufficiently diluted the volunteer bias found among those who were anxious to contribute their histories; we are not particularly interested in having more from the group, hence we stop. Now the question arises, inasmuch as the whole group was solicited (even though indirectly), is the refusal rate

50 per cent? Or are only those who were individually and briefly solicited to be considered refusals? Or should we count only those who rejected the second and serious solicitation? The problem is in some instances hopelessly confused by the fact that we often do not record the name of the person solicited and cannot determine whether he or she subsequently gave a history to another interviewer.

Nevertheless, it is indefensible thus to excuse ourselves from considering the problem of refusals as a statistical factor. Consequently, in obtaining the “hospital sample,” the only major interviewing endeavor in recent years, we arranged our sampling procedure so that an accurate account of refusals could be made. In this sample we first ascertained the males who were eligible for inclusion in the control group, and we then solicited each person in specific terms so that a clear-cut acceptance or refusal resulted. Out of 164 requests we suffered six refusals; also two men began interviews but refused to finish.

While we have dealt thus far with the question of sampling within the groups chosen for this purpose, we have not touched on the equally important question of which groups were chosen and why. Since at this point our concern is with the 477 males constituting the control group, this is no place in which to discuss in detail the sampling procedure of the entire research, and a brief description must suffice. The sampling procedure was to ascertain the weaknesses of our existing sample and with these in mind to select, from whatever groups seemed available to us, those that would best remedy the weaknesses. For example, at one time we realized that we had very few older, never-married women in our total sample; consequently, we arranged matters so that we were invited to address an educational conference whose membership included a large number of never-married female teachers, many of whom were of the age we desired.

While we are satisfied with our sampling within each chosen group, we are not satisfied with our sample of groups. Various imbalances in terms of age, education, religion, and other factors exist. In selecting our control group—which we wished to make as similar as possible to the prison group and sex offenders with regard to socioeconomic status —these defects hampered us. However, in view of the magnitude of our task and the limited means at our disposal we feel no apologies are called for.

With two exceptions, the term “sampling procedure” can scarcely be applied to our prison group. In the early stages of the research, when much interviewing was being done at Indiana correctional institutions, Dr. Kinsey did not view the inmates as a discrete group that should be differentiated from people outside; instead, he looked upon the institutions as reservoirs of potential interviewees, literally captive subjects.

This viewpoint resulted in there being no differentiation in our 1948 volume between persons with and without prison experience. By 1953 when we published our second volume we had found that the sexual behavior outside prison displayed by persons previously or subsequently imprisoned differed from the sexual behavior of persons never imprisoned; consequently, persons with prison experience have since been treated separately. At any rate, the great majority of the prison group was collected omnivorously without any sampling plan—we simply interviewed all who volunteered and when this supply of subjects was exhausted we solicited other inmates essentially at random.

One instance of planned sampling in the prison group occurred at San Quentin when Dr. Gebhard and Dr. Pomeroy asked the prison administration to select an inmate group it felt would best represent the total inmate population. The administrators chose those who were working at the quarry; here the only known bias was that the men could not be serious escape risks and had to be in at least average physical condition. There were some 50 in all, and we made an attempt to interview each one. Of these men, three refused and one, through some oversight, was not solicited; counting him, this gives a refusal rate of 8 per cent. This quarry sample we compared to the total prison group on a small number of behavioral items and the differences appear inconsequential.

The second instance of planned sampling took place at Soledad where all males who appeared obviously homosexual or who proved to be problems because of their homosexuality were segregated in one wing of a building—Z wing. We decided to sample Z wing as thoroughly as possible, and succeeded in interviewing 111 males—everyone in Z wing—plus two who had recently been returned to the general inmate population.

The procedures used in accumulating our sample of sex offenders varied according to circumstances, and each institution must therefore be dealt with separately. In each we found more sex offenders than were officially listed; men are listed in prisons on the basis of their current offense. Prior offenses, unless notable, are often forgotten and some minor ones may not appear on official records.

At the Indiana State Farm we had no plan of sampling—we simply sought out sex offenders and, after a time, avoided the more common types of offense (e.g., statutory rape) and directed our efforts toward the rarer types.

At San Quentin, where we interviewed intermittently from 1949 to 1954, we originally followed a rather simple pragmatic plan: to obtain a numerically adequate sample of every type of sex offender. This led, naturally, to an eventual emphasis on the less common types. Toward the end of the San Quentin interviewing, in November 1953, we inaugurated a more rigorous sampling plan. We first obtained a census of the inmates currently serving sentences for sex offenses and then decided to attempt to interview all the men convicted of certain unusual offenses and to make a random sample of men convicted of other commoner offenses.

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