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Serious marital or sexual problems are unlikely to be improved by sterilization of either partner, and one of the most important tasks of the pre-sterilization consultation is to identify the hopes and expectations of the couple. Not infrequently the man may hope that it will make his wife more interested in sex. One man blamed his wife’s lack of desire on the Pill, and when it was suggested that coming off it might not necessarily make her better he said, ‘You mean I will have made the ultimate sacrifice for nothing?’ He decided to postpone the operation, but interestingly he came back six months later wanting to go ahead. At this stage the doctor felt happier as the patient now had realistic expectations of good contraception, and he could accept that anything else would be an unexpected bonus.

The operation of sterilization is often surrounded by powerful fantasies of what it may do to the self or to the partner. A man may hope that vasectomy will improve his own sexual performance.

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This chapter is written from the point of view of doctors working in Britain with patients from other cultures, rather than about doctors who work abroad. This author’s experience as a general practitioner working with recent immigrants in Tower Hamlets, a deprived inner city area of London, will illustrate the most obvious problems of cultural diversity. The fact that most of the indigenous patients are Cockney, and have a distinct language as well as cultural tradition concerning such things as food and commerce, demonstrates that the problems are not only to do with racial issues. It is this author’s proposition that when working with individual patients it is just as easy to overemphasize the influence of culture as it is to be insensitive. To be able to provide the best service to patients doctors need to be able to judge the importance of all the influences surrounding a doctor/patient relationship. If we are skilled in analysing the emotional climate within our relationships with patients, we will not be so greatly daunted by the constraining effects of external differences. Before trying to understand the effect of some of those differences on the provision of care in Britain, we need to look briefly at the situation in the countries from which many of Britain’s recent immigrants have come.

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Most people feel okay for several hours following chemotherapy treatments; they are able to eat, work, do errands, and so forth. Usually some reaction occurs four to six hours later; there are some people who experience little reaction until twenty-four or even forty-eight hours later. On the other hand, some people feel the worst twelve or twenty-four hours following treatment. You will have to see how you feel.

Expect that the first treatment will be a new experience both for you and also for those caring for you. If it goes well, the odds are good that the remaining treatments will, too. Your oncologist may decide to change or adjust the dosage or the anti-nausea medications depending on your reactions following treatment. You may or may not experience a variety of side effects; if you want to know what to expect, ask your oncologist or your chemo nurse to tell you about these. Realize that you personally may experience some, none, or all of the possible side effects. Realize, too, that each treatment cycle may be different.

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An annoying complication of axillary dissection (done either with mastectomy or lumpectomy) is lymphedema of the arm. Lymphedema is chronic swelling of the arm due to the accumulation of fluid as a result of lymph node surgery. This surgery can interfere with normal drainage. Lymphedema occurs very rarely following the limited type of axillary dissection usually done at the present time, but it does sometimes occur. Another temporary complication is limited motion of the shoulder. Normal activity right after surgery and active exercise ten to fourteen days later will alleviate this. If you find that you have limited use of your arm, ask for a referral to a physical therapist. If you have a problem, choose loose-fitting tops with deep, roomy armholes and be careful not to wear tight cuffs at the wrist or tight jewelry on that side. Try to avoid cuts or scrapes on the affected arm. Also be very careful about hangnails, paper cuts, and fissures in the cuticles. Be sure to apply a topical antiseptic and an adhesive bandage to speed healing. When you have a manicure, be sure to tell the manicurist to exercise extra caution. Wear gloves when you garden. Keep your hands moisturized. Seek medical attention immediately if you see signs or symptoms of an infection in that arm or hand (redness, pain, swelling, warmth). YOU WILL ALWAYS BE AT RISK FOR LYMPHEDEMA FOR ALL OF YOUR LIFE. THESE RULES APPLY NOW AND ALWAYS.

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The impact of your cancer on your grown children will be significant. Frequently young adult children—that is to say, those college age or slightly older—may seem quite unconcerned about your diagnosis. This is usually perplexing and even hurtful to the mother, but it may help to know that it is normal. Their apparent nonchalance masks very real worry. They are trying to learn how to be independent of you; this sometimes makes it too difficult to let you know how frightened they are. If this is the case with your children, know that sooner or later, they will express the true depth of their concern for you.

Daughters worry both about you and about themselves; their risk of breast cancer does increase a little with your diagnosis, and they will need to be extra careful about monthly breast self-exams, and, after the age of thirty-five, about mammograms. As mothers, we may find it painful to face the fact that we have inadvertently, through no fault of our own, slightly increased our daughters’ breast cancer risks. Remind yourselves that your daughters will be likely to take special care of themselves, since their awareness has been heightened. Also, remember that real advances are being made in prevention and treatment, and we can hope that the incidence of breast cancer will be much reduced in our daughters.

In thinking about the impact of breast cancer on your children, remember that this is not just a disease that affects female body parts. Breast cancer, like many other cancers, affects the whole person and her family. In some real sense, the whole family can feel stricken by this insidious disease.

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The reality of medicine today is that you may not spend even a single night in the hospital throughout your breast cancer experience. We have even heard of women being discharged on the same day that they have undergone mastectomies. If you know that you are not feeling well enough to go home, say so and say so loudly. You may need to make more of a scene than seems comfortable, but just say no!

? If you are sensitive to noises, pack your Walkman and favorite tapes. Consider using earplugs; you can buy them in any drugstore.

? Even if you are not sensitive to noises, music can be nice to have. Bring something you enjoy listening to.

? You may be sharing a hospital room—an eye mask helps you nap if you’re sensitive to lights.

? While hospital gowns aren’t beautiful, they are practical because they have shoulder snaps or ties. They may be easier to use for the first few days.

? Leave favorite pieces of jewelry, watches, and rings at home. Your family can bring them when they visit.

? Bring your cosmetics, favorite cologne, postcards, or notecards you like to look at and some family pictures. Soft, stretchy headbands or pretty barrettes can help keep your hair under control until you can wash it. You might want to bring some dry (powder-type) “shampoo” to fill in until you can take a shower. Bring (or ask someone to bring in) a blow dryer.

? If you are going to be in the hospital for several days, consider taking some nail polish and asking a friend (after your surgery) to give you a manicure and/or pedicure.

? Tuck some magazines into your hospital kit. It is even possible that you will have the energy to read a book, but bring only light and entertaining reading.

? Bring your own pillow in a pretty case.

? It is okay to bring your favorite quilt, too.

? If you live alone, you may need help at home for a few days. There are resources in every community. Ask your nurse or social worker. Some hospitals have programs prior to your admission that enable you to get this information. When you are given the information about your surgery ask whether there is someone with whom you can speak about home care assistance.

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David Spiegel, a psychiatrist at Stanford University, published an important study in 1989 about the positive effect of support groups on the longevity of women with breast cancer. Although his groups were all for women who had metastatic breast cancer, he found that those women who were in support groups lived longer than those who were not. Although these studies have not been duplicated in women with early breast cancer, even in the absence of solid data, it seems reasonable to think the conclusions would be similar. Many studies have documented the positive impact of good social supports for individuals with all kinds of cancer, and there is no social support better than the right group.

There are a number of places to ask about groups. The suggestions we made earlier about how to find a therapist would all apply here, too. Additionally, programs such as the Wellness Community or Gilda’s Place offer a number of support groups. Ask whether the groups are professionally led or are peer support groups. Ask who the participants are, and particularly ask about their stage of illness. It is our bias that no one’s needs are best served by being in a group comprised of women who are dealing with all stages of breast cancer. You would be unnecessarily frightened, as women who are very ill are dealing with different issues than those you currently face.

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One of the interesting aspects of this study is the offender’s impression of how his parents got along together when he was in his mid-teens. There proved to be a strong tendency for the parents of the incidental offenders to have gotten along better with one another than the parents of the patterned offenders.

In spite of these differences in interparental adjustment there appear to be no significant differences between the groups with regard to the proportion whose parental home was broken by divorce, separation, or death. Similarly we found nothing worth comment regarding their ages when the home broke up or their subsequent living arrangements.

The adjustment of the future offender with his parents proved to be a significant item. In three groups the incidental offenders bad definitely better mother relationships, and this same tendency is visible in a fourth group. Of the remaining two groups, the patterned incest offenders seemed to have the better relationship and among the aggressors no meaningful differences between the incidental and patterned offenders exist.

The situation with regard to adjustment with the father is similar: with but one exception (the incest offenders vs. children) far more incidental offenders got along well with their fathers than did the patterned offenders.

Evidently a good relationship with one’s parents is, except for incest offenders, a factor in the prevention or inhibition of patterned offense behavior.

When asked whether they got along with both parents equally well or whether they got along better with one or the other, consistently more incidental offenders than patterned offenders reported they got along equally well with both. This lack of preference is a “healthy” sign and it is gratifying to find that here it is a characteristic of the incidental rather than the patterned offenders.

Examination of the ratio of brothers to sisters revealed no consistent trends, and in most groups no appreciable differences. However, in rank-order of birth there is a tendency for the patterned offenders to be the only child (true in five of the six groups) or the eldest (four of six groups).

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Most sex-offender groups have fewer members with juvenile records than has the prison group, and their offenses are generally less serious. Few committed juvenile sex offenses, but for these few the offenses are fairly predictive for their adult offense behavior.

The sex offenders in general become involved with the law later than the members of the prison group. Only in the prison group and two sex-offender groups did the average individual experience his first adult conviction before age twenty. Among the sex offenders there is a gap of from about three to 12 years between their first criminal conviction and their first conviction for the offense for which they are named.

About half to two thirds of most sex-offender groups had purely sex-offense convictions. Taking all convictions into account, for most groups between half and three fifths were for sex offenses.

Half of the sex-offender groups had more convictions per capita than the prison group and half had less; the range is 2.4 to 5.5. Those who use force and those whose sexual objects were children tend to have been convicted most often.

The commonest nonsexual crimes of the sex offenders are those loosely labeled as vagrancy or disorderly conduct: from one fifth to one half of the nonsexual convictions are for offenses of this nature. Crimes against the person are significantly numerous only for the aggressors. Other sex offenders tend to be nonviolent.

Specificity, the repetition of sex offenses of the same type, is rather high among most sex offenders. The incest offenders and the homosexual offenders vs. adults are particularly apt to confine their offenses to those which earned them their labels. Among the latter, about eight out of ten of their sex offenses were against other adult males. The aggressors and the homosexual offenders vs. children are the least inclined to repeat. Only about half of the offenses of the aggressors vs. children and minors were specific as to type.

Our data concerning recidivism are seriously deficient in that our sampling generally was confined to offenders currently in prison—i.e., the men who were not recidivists (sexual or otherwise) were men still serving their first sentence. Nevertheless it appears that the aggressors (especially aggressors vs. children), exhibitionists, and peepers are the most recidivistic both for sex offenses and total offenses, and the incest offenders are the least recidivistic. Those whose sex offense involved a child tend to be more recidivistic than those whose offenses involved a minor or adult.

In general there is no evolution from minor to serious offenses. There is a pronounced tendency among most sex-offender groups for the second offense to be of the same type as the first. In cases where more than two offenses have been committed there is a tendency for the use of force or threat to become less common in the third or subsequent offenses.

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While coitus and orgasm are for all practical purposes synonymous in the male, the two must be considered separately in the female. Since we were able to interview only a few of the wives of the men in this study, we have necessarily relied upon the man’s report on his wife’s orgasmic response. We are keenly aware that some men are essentially ignorant of how often their wives reach orgasm in coitus and that other males have been deceived by their wives in this respect. Furthermore, we know the masculine tendency to look upon one’s own sexual activity through rose-colored glasses, and easily persuade oneself that one’s female partners reach orgasm frequently. With these qualifications in mind we thought it best to focus only upon the extremes, and hence calculated the percentage of the years of marriage during which the wife was minimally responsive (orgasm no more than once in ten acts of coitus), moderately responsive (orgasm in 11-89 per cent of the coitus), and very responsive (orgasm in 90 per cent or more of the coitus). Thus, for example, a figure: of 50 per cent in the very responsive category means that during half of the marriage the wife reached orgasm in coitus 90 per cent or more of the time.

Examining this calculation, it is at once obvious that the great majority of sex offenders had (according to their reports) unusually responsive wives. All but two sex-offender groups reported that in over half of their married years their wives readied orgasm nine times out of ten or better. Those reporting the most responsive wives were the peepers, the aggressors vs. minors, and aggressors vs. children; for three quarters or more of their married lives the wives of these men had a high orgasmic response.8 These figures exceed those which married women reported and which we published in our volume on female sexual behavior.” It is unfortunate that these three groups are the three smallest in terms of ever-married males: 25, 14, and 18 respectively. At the other end of the range one finds the control group (47 per cent), exhibitionists (46 per cent), and lastly the homosexual offenders vs. adults (39 per cent).

About all one can say is that by their own reports the sex offenders cannot ordinarily claim lack of sexual responsiveness in their wives as a factor contributing importantly to their offense. Before closing this subject, we must call attention to the fact that the three groups claiming the most responsive wives were groups which sought gratification outside of marriage by the most extreme methods—violence (the aggressors ) and stealth (the peepers). The aggressors are also notable for their ability to develop ego-gratifying errors in judgment as to the responses of their sexual partners: their victims eventually enjoy their rape and their wives nearly always have orgasm.

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