Mens Health Blog. Medical Blog

The most important skill that doctors learn in seminars is to tolerate not knowing. Neither the patient nor the docor has the truth, which has been described as ‘a reality that exists in between; in between two people seeking it; in between psychoanalysis, sociology, psychology, economics and religion . . . truth can be seen or glimpsed, not possessed’ (Symington, 1986). Psychosexual doctors learn to stay in ignorance with their patients, searching for a glimpse of the truth, for as T.S. Elliott (1954) says in his poem East Coker

In order to arrive at what you know

You must go by a way which is a way of ignorance.

In order to possess what you do not possess

You must go by the way of dispossession.

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It is important that the patient’s agenda always comes before the doctor’s agenda. The patient’s agenda may be overt or covert (the hidden agenda). The agenda may include that of the partner, whether present or absent at the particular consultation. Family planners encourage patients to bring their partners with them to a consultation. Seeing a couple together may be beneficial so that the method chosen can be one that suits both partners.

Neighbour calls the line which the patient has been rehearsing in the waiting room the ‘opening gambit’ (1987). The patient may well have more than one of these at the ready. Perhaps a ‘respectable’ line such as, ‘The Pill is giving me these awful headaches, doctor’, and a line about her fundamental problem such as, ‘My husband is unemployed and has lost all interest in sex’, which could be used if the time is felt to be ripe. The respectable line is far more likely to be used with its lower risk, if the doctor does not make good eye contact initially or if he pre-empts the patient’s offering by asking a question.

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Miss P. had correctly observed the connection between the use of condoms and her soreness; if it had not been for the defensiveness about her explanation of her partner’s need for her to avoid pregnancy it might have been accepted at face value and not explored further. How very important it is to pay attention, not just to what is said, but the manner in which it is said.

Patients may present many physical complaints. One attended for a repeat of her contraceptive pill following a termination of pregnancy. She complained of an offensive discharge present since the termination and wondered if she had an infection. Examination revealed a very normal looking vagina and the swabs were all negative. The doctor was then able to discuss with the patient what the termination had meant to her and explore her disgust with herself for what had happened. Another, respectable and dowdy patient, married to a boring, pompous older man, asked to be fitted with a diaphragm and then returned repeatedly asking for an examination and swabs to be taken. The doctor was irritated by the apparendy meek approach from the patient and was reluctant to repeat the examination. The patient always managed to manoeuvre the doctor into taking more swabs. When the meaning of this (looking for ‘badness’) was explored, the patient eventually revealed that she had been a wild teenager and had fantasies that her vagina was the place from which this bad and dangerous person might erupt again. Coming to terms with herself, she was able to recognize that she was deeply unhappy in her relationship with this man whom she had married hoping that he could control the dangerous side of her nature.

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It is clear from all the literature on sterilization that there is a general consensus that counselling before the operation is seen as an important part of the process. Methods are suggested and contraindications to sterilization are listed (Elias, 1991). It is also clear that in many situations counselling in any true sense of the word is honoured in its absence. Perhaps this is because there is a feeling that it will be impossible to elicit any information that the patient is unwilling to share at interview.

Several members of the Institute of Psychosexual Medicine have studied aspects of counselling for sterilization and have discussed their findings. A summary is to be found in Tunnadine (1982). This author identified guidelines which include the fact that the couple seeking sterilization should have a good relationship and sex life, that both partners should wish for the procedure and that their expectations should be realistic. This group of widely experienced doctors emphasized the dangers of performing a sterilization at a time of emotional crisis. On occasions, considerable expertise may be needed on the part of the counsellor to avoid this. Their skills can be developed during seminar training organized by the Institute of Psychosexual Medicine.

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Akhtar lived with her elderly parents, and her son and daughter-in-law, and the appearances of the household indicated a traditional Hindu family. A visit concerning back pain allowed the GP to observe the packet of contraceptive pills by Akhtar’s bed. As they had not been prescribed by the GP, and as she had thought that Akhtar was divorced, she checked with the patient that they were in fact hers. During another consultation the doctor felt confused about the way in which Akhtar talked about her family. This confusion was voiced, and although Akhtar at first tried to maintain that she was married, she subsequently revealed her rather miserable life as the downtrodden mistress of an English colleague at work. Her UK-born daughter-in-law who had, perhaps surprisingly in view of her mother’s emancipation, married by arrangement, found no difficulty choosing the diaphragm as the most sensible contraception for spacing her pregnancies, despite the doctor’s idea that Hindu ritual would prohibit touching the perineum.

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