However, discussion of sexual matters in the seminar can make the subject more comfortable. Doctors attending seminars have said that it is a safe place in which to practice the discussion of sexual details, and they gain greater confidence to listen to, or to broach sexual topics with their patients.
Setting clear training boundaries that exclude personal sexual revelations and that tie all discussion to a specific case, allows for a study of those difficult moments in the consultation when a feeling of sexiness develops in the room. For the woman doctor faced with a man who produces an erection, the embarrassment can be great for both parties. It may be possible to see such moments as uncon-sicous defences on the part of the patient (Skrine, 1987). Certainly the doctor is usually de-skilled and has to retreat to the safety of the prescription pad, the ordering of tests or a referral to another doctor. During training the doctor can learn to cope with such moments with some degree of equanimity.
*363/197/1*
Although doctor had a special interest in psychosexual therapy and some skill in this field, his personal feelings made therapy with this woman, or her husband, a potential minefield. The professional pride of this doctor nearly led him to embark on a dangerous offer of therapy. He could recognize that, because of his training, he had been able to stick with the real problem – that the woman wanted to change her method of contraception without the existence of a logical acceptable reason. He knew from his previous experience with similar encounters that an emotional reason was likely. He had several bright ideas: she might feel she was too old to be continuing on the combined oral contraceptive, or that she might want a less reliable method in order to risk pregnancy without taking a definite decision to start a family. The failure of these ideas to strike a chord with the patient reminded the doctor that each patient is unique and that experience gained from other patients is of no help in understanding what is happening with this particular patient. Only when he waited, in ignorance, for her to tell him what the problem was for her, did he discover the underlying difficulty. He knew, too, that if the husband had come to him with the problem of premature ejaculation, he might have been able to help him discover why it happened. Perhaps his first wife had taken too much from him and he wanted subconsciously to retain the sexual pleasure for himself; perhaps he had always had this pattern and could not see any difficulty, or any of the myriad other reasons why it occurs. Then he could perhaps help him to make the necessary changes to ovecome the precipitate ejaculation. The doctor’s difficulty was his nonprofessional partisan feelings, which made referral elsewhere a preferable option. He would have to propose this to Mrs S. without making her feel rejected.
*324/197/1*
Sometimes any contact with a familiar doctor may be perceived as too threatening. A young girl may be unwilling to reveal her sexual needs to a doctor whom she regards as an extension of her parents, particularly her father, and therefore (she feels) bound to disapprove. The occasional publicity about parents being told about their daughter’s sexual activity by a doctor, or even the presence of a rumour about lack of confidentiality, will further discourage the timid or unsure. This part of the growing up process which has to be kept hidden from parental supervision and knowledge, the secret inner world, this search for the separate individual self which is the adult into which the adolescent is developing, prevents the not-yet-quite-adult from consulting those he or she views as being in the parental role. Doctors, teachers, school nurses, as well as parents, all recognize the difficulties of reaching past the defences of the often sullen and rebellious teenager or young adult. Particularly if there are difficulties – the unsuitable boyfriend, a fear of infection or abnormality, failure of erection, pain or dissatisfaction with intercourse – a stranger may need to be sought out. A clinic or doctor unknown previously, perhaps recommended by a friend as sympathetic, is consulted instead of the familiar family doctor.
*286/197/1*
In the next two case examples, not only were the patients young at the time of their vasectomy, but there is the additional factor that with both men the procedure was undertaken for the sake of their partner.
A couple came for advice about their infertility. They were in their early 40s, the man dressed in a neat business suit, and his wife also formally dressed. She was so distressed that the overwhelming impression was of a woman with a mass of wild auburn hair and barely restrained emotion. They had married at 18 and had three adult children. After the birth of the third child, the husband, aged 22, had undergone a vasectomy in the puerperium. There appeared to have been no encouragement for him to discuss his decision with his wife. Initially the situation seemed acceptable, but as the years went on and the children grew up, the couple became increasingly distraught. They found adoption was impossible and fostering did not meet their emotional needs. They both regretted the operation and reversal was undertaken but pregnancy did not follow.
*248/197/1*
Her situation was discussed and the importance of failure rates examined. Ann said that in the event of failure of the method she would find termination of pregnancy very difficult to even consider, as she felt it would indicate that she had no value. It was agreed that the injectable contraceptive would give her secure contraception and be the safest option in view of her total immobility. This method protected her against pregnancy and induced amenorrhoea which she found a blessing. Many times over the years the couple and their doctor have discussed the prospect of children. Ann and John have now decided that the risk to her health and life is too great. Ann has needed to feel that she had the choice and that she had the capacity to conceive like everyone else. Now, after discussion with her husband, she has made her own choice rather than having a decision thrust upon her by a well-meaning professional.
After some years on injectable progestogens she dreads the thought of periods again and she is currently discussing the possibility of sterilization and endometrial ablation. Further long-term use of the injections has to be considered carefully in view of the possible risk of osteoporosis, which is already a risk factor for her due to her immobility. It is important that Ann and John feel comfortable with the decision made.
*210/197/1*