Psychosexual medicine has evolved a discipline of looking at difficulties by concentrating attention on the doctor/patient relationship and also on what happens during the genital examination. A man may have his closest feelings defended by the fear that he is not normal – perhaps not as aggressive as the average man. This may form a barrier to the useful development of the relationship with the doctor. Some of the barriers here have been described by Tunnadine (1983).
It requires careful listening to hear where the vulnerability lies, particularly with men, as the opportunities to examine feelings via the exposure of the genitalia are less frequently available than they are with women. When such an examination is possible it can be excitingly enlightening.
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Often a woman has managed to be seen on her own during many visits to her GP and the gynaecology outpatient clinic without the inclusion of her partner. He may well have attended the clinics but somehow, because he was not invited into the consultations, he remained in the waiting room, on the fringe of this ‘women’s world’. How does this happen? Patients’ understanding of infertility problems revolve around the premise that it is almost entirely a female deficiency. Just in the same way that society has equipped itself for the fertile, so all assumptions and efforts at treatment have been tailored to the female side of the problem. Therefore it is so often the woman who appears first in the surgery with the statement, ‘We’ve been trying for a baby for so many months now, and I just don’t seem to be able to get pregnant.’ Because it is the woman who is there in front of the doctor it is usually she who is the focus of all the initial tests, without any discussion between the couple and the doctor. Such discussion with the couple, to exclude any psycho-sexual problems, is as important as the gamut of blood tests that are carried out. It can also act as a baseline for the recognition of developing difficulties during sometimes lengthy treatment.
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Miss B. was a pretty blonde woman who requested abortion. She came to the clinic accompanied by her boyfriend. Immediately, she stated that she did not want an abortion but that he did. Her anger was obvious and it seemed he had been brought to the clinic to suffer. She had come off the Pill some months earlier ‘to give her body a rest’, they had not used contraception and they were both apparently aware of the possible consequences. He went on to say that the relationship had been going through difficulties and he did not feel she was mature enough to look after a baby. She felt she could do so perfectly well if he supported her. They both realized that they were using this pregnancy to sort out their relationship once and for all. They wanted more time to talk and made another appointment. Miss B. returned alone, looking more composed. Her boyfriend had agreed to her keeping the baby but had placed so many conditions that she felt her life would be intolerable. She wanted an abortion and hoped that one day she would be able to have a baby with someone who was right for her.
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This is not a perfect nor a 100% successful method, perhaps easier to cope with because of, not despite, these apparent drawbacks. The risk factor, the possibility of pregnancy, is vital to some women if they are to really enjoy intercourse.
Mrs C. definitely knew that she and her husband did not want any more children. However, she could not contemplate sterilization, for herself or her husband. She cheerfully started taking the Pill, but three months later she was back, looking unhappy. No real problems, except . . . well, she quite liked sex, but . . . she could not come any more. Could it be the Pill? Different contraceptive pills were tried, to no avail. It was decided to try the coil, despite the doctor’s worries about the risk of pregnancy. She returned happier, the periods were ‘miserable’, but sex was good again. The doctor initially thought that this depression of libido was caused by the Pill but Mrs C. confided that she had realized that at the point of orgasm she silently called to her husband, ‘Give me a baby . . .’ She used this fantasy to release herself sexually, and the very unreliability of the coil was its best point.
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Religious views can also be used by a patient to explain to herself deep, unexpressed fears of the reliable contraceptive methods, as well us her ambivalent feelings about another baby that she may not fully recognize.
Mrs B. was 23 years old, a strict Jehovah’s Witness with three children under the age of three years. After a discussion about methods, she was adamant that she wanted no foreign chemicals in her body, and that she wished to rely on natural family planning, even although she insisted that she did not want another child for five years. She seemed unable to hear what the doctor said about the benefits and effectiveness of the oral contraceptive pill. The doctor, though tempted, felt that discretion was the better part of valour and did not persist in advocating a more reliable method. Instead she taught the woman how to predict ovulation using both the thermosymptal and mucus method. A year passed then Mrs B. became unintentionally pregnant. She could not contemplate an abortion. She had the child, a boy, which was what she wanted. After this pregnancy she decided to take no more chances. She opted for the contraceptive pill, which she has taken for six years without problems.
The occurrence of an unplanned pregnancy and the birth of another baby had produced a change in the way she perceived the various factors in her life. Her need for reliable contraception, and perhaps also the resolution of her ambivalence about wanting a boy, was strong enough to override her fear of chemicals and her religious influences.
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