The Health Blog

Sometimes doctors are given second chances, and it is possible that the belated recognition of the ‘teacher’ who was provoked in the doctor and nurse by the patient will make it possible to explore the ‘childish’ behaviour at the next visit.

Other feelings in the doctor can be seen to have developed in response to the patient. Irritability, anger and even a particular degree of sadness or despair become subjects of study. Indeed, the feelings may be projected from the patient, via the presenting doctor, into the group. For instance, unconscious aspects of the patient may be seen particularly clearly when her or his ambivalent feelings reveal themselves by a split in the feelings and sympathies of the group members themselves.

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Contraceptive consultations are favoured occasions for revealing overt or covert sexual problems. By attending for advice on birth control, patients are already revealing that part of them that is sexual, and the subject of difficulties with their sexual life can be broached with less difficulty (it is never easy). Doctors and

nurses concerned with giving contraceptive advice should be comfortable discussing sexual matters. They need to be skilful in their ability to receive and manage their patients’ confidences and to recognize when and how to refer those they are unable to help.

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Expectations of what will happen during consultations for family planning influence the choice between clinic or general practice, or between known or unfamiliar doctors.

Patients may attend a community family planning clinic because they have heard that patients have a ‘thorough examination’ there. On the first attendance the patient may look disappointed when she is told that the examination of that (sexual) part of her body – her genitals and breasts – can be left until later. She wants an examination of this part of her about which she has unspoken anxieties -perhaps doubts that it is ‘good enough’ to be shown to a partner, or that, untried, it may not function well enough, or might become out of control.

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A very anxious and distressed woman in her mid-30s came into a family planning clinic asking for postcoital contraception because of extramarital intercourse the night before. She explained that she was married to a long-distance lorry driver and they had three children. Four years previously her husband had undergone a vasectomy. Since then she had been surprised to find she could not allow sexual intercourse. She said she had never enjoyed it, but had assumed that things would improve once the fear of pregnancy was removed. Instead, she was devastated to find there was a marked deterioration. The doctor asked her why she thought this was so, and she said she had found it more exciting when there was a chance of pregnancy. Then she added that she did not think it was fair that her husband could now behave as he liked on his frequent absences from home, and that he need fear no repercussions now that he was sterile. The doctor asked if she had been distressed about her husband’s infidelity before the operation, and she said she had preferred not to think about it then. Although she had been angry, she had been so busy she had put it to the back of her mind. Recently, she had become frightened about her own lack of sexual feelings and she had drifted into a casual relationship with a friend, to see if she could respond to a fertile man.

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‘In general, Third World service programmes are primarily accountable to their governments and/or western donors who fund them.. They often have demographic rather than service priorities’ (International Women’s Health Coalition, 1986). Thus individual needs and the quality of the service are pushed down the list of priorities, and the acceptability of a method and greater security against pregnancy are considered more important. The service can become completely impersonal; for example, in Mexico it is policy that 90% of women who have a termination of pregnancy should have an IUD fitted. In Indonesia, poverty certificates have to be shown for access to some contraceptive services. Moroccan women queue in waiting halls without their underwear, to speed up throughput. It can be seen that the needs of women and the needs of the population can be at odds when resources are limited.

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