Archive for April 7th, 2009


Tuesday, April 7th, 2009

This process takes place continuously while a doctor is consulting but needs to be practised for full advantage to be gained. There are two elements. First, recognition of the feelings in the doctor engendered by the patient may help him or her to understand the patient’s problems, particularly if a problem involves a relationship with another person. In Chapter 1, Elphis Christopher describes beautifully how the process of becoming entangled with the patient’s problem allows feelings in the doctor to surface. Freeling and Harris (1984) categorize the doctor’s feelings into those that are unconnected, indirecdy connected and direcdy connected. Unconnected feelings can arise from the doctor’s own domestic problems or from an emotion aroused by the last patient seen. Indirectly connected feelings may arise when the doctor identifies a problem he or she has experienced, such as a marital or sexual difficulty. Both of these categories of feeling lie strictly in the domain of the doctor’s personal life. Directly connected feelings may be used legitimately in the consultation. Training in psychosexual medicine helps doctors to appreciate when it may be appropriate to feed these back to the patient. However, this must be done carefully and sensitively. This skill is an intuitive one which is a far cry from the conventional history-taking type of consultation that many doctors were taught at medical school.



Tuesday, April 7th, 2009

Miss L. was an attractive 18-year-old. She had come to have a coil fitted. The doctor asked why she wanted to change her method. She stuck her jaw forward and said that she had been on the Pill for two years and had gone off sex. She was sure it was the Pill and wanted a coil instead. She looked away from the doctor, not wanting any more discussion (or perhaps to avoid persuasion that this was not the right choice). The doctor waited but no more was forthcoming. ‘Tell me a bit more about when you first noticed you were going off sex,’ she prompted. With lots of ‘urns’ and encouraging nods from the doctor, Miss L. hesitantly told her story. She had known her boyfriend since she was 15, and she thought it was time that they got engaged but he did not want to commit himself. As she told the doctor about keeping her evenings free for him and how he then went out with his mates instead, her anger became evident. The doctor picked this up and used it to show her how dissatisfied she was. As they talked. Miss L. gradually realized that she could not change her young man’s behaviour and became thoughtful. She decided to postpone having a coil fitted. The next time she was seen, for an unrelated problem, the doctor noticed that she must have run out of Pills and asked her about it. Miss L. explained that she had stopped taking the Pill. ‘We had a big bust up. I started playing badminton with a girl from work and was out one night when he wanted to see me. I told him he didn’t own me and some other home truths about how selfish he was – he didn’t like it at all and I haven’t seen him for weeks now. Good riddance, is what I say!’ and she flashed a smile as she went out.



Tuesday, April 7th, 2009

The acceptance of the patient’s sexuality is as important as prescribing the right method. A nonjudgemental acceptance and a willingness to allow the patient to explore any feelings of guilt, embarrassment and sometimes even shame is as important as the provision of postcoital contraception. It is important that such feelings are dealt with when they are offered, for if left unresolved they can be very destructive. Such help need not be time consuming and it can prevent subsequent problems in sexual health and relationships which are a potent source of ill health (Sims, 1992).

Younger doctors and nurses may feel uncomfortable when patients old enough to be their parents need help with sexual matters. With experience they will notice that only with some patients do they feel embarrassment, and such a feeling is usually a response to patients who have some feeling within themselves about their age and sex. Indeed, some people may choose, either consciously or unconsciously, to consult someone whom they perceive to belong to a generation that knows about sex and will not be easily shocked.

Contraceptive and sexual problems at this age may be a symptom of difficulty in adjusting to the inevitable changes in role and pattern of life.



Tuesday, April 7th, 2009

Forida Akhtar, a 35-year-old Sylheti woman, complained of pains in her back and shoulder. No diagnosis could be made from routine clinical assessment and over a matter of weeks she became more and more uncomfortable with the pain, finally volunteering that it was, in her view caused by her coil. Her husband who was sympathetic and attentive, readily concurred, and although the doctor felt that the pain could be psychosomatic, she was not confident that the IUCD was the cause of the problem. With little room to negotiate, the progestogen-only Pill was prescribed while the couple received instruction in barrier methods, their preferred choice once the coil was removed. Once released from the necessity of putting up with the coil, the couple revealed that they had never felt that the coil was allowed by their religion, and were relieved to be able to do without it. The initial choice of a coil had been made mostly on medical grounds.

As in so many aspects of their lives, newcomers to the West are in a state of flux, and fall somewhere between the traditions of their homeland and the current mores of the UK. If nurses and doctors are sensitive to the changes that are taking place, often very quickly, the patient can use them as facilitators, and thus find their own position in their particular cultural and social context. For a couple who previously believed that all children should be accepted, and that no contraception should ever be used, the experience of one years’ infertilty on the basis of postponing the next pregnancy rather than limiting the family can be profound. The essential part of the learning process is that their experience of infertility is achieved with contraception rather than by geographical separation.



Tuesday, April 7th, 2009

Jean Jones has a physical disability and some degree of mental handicap. She would love a normal relationship that would end in marriage and possibly children. She lacks confidence. At the first sign of any interest shown in her she pours her loving feelings upon the prospective partner and her demands and expectations overwhelm him and he takes fright and disappears. It has been necessary to explore this pattern of behaviour with her so that she can share her feelings and understand what is happening. She has begun to feel that it is acceptable to need, to want and to have relationships, and it has been possible to begin to explore her underlying anxieties. She is beginning to gain some insight into her desperate need to grab hold of a new partner lest this be the last opportunity, for such opportunities are indeed rare for her. There is still much work that needs to be done with this patient if she is to have a chance of finding a fulfilling relationship.