Doctors will need to follow their routine medical procedures before starting a woman on the Pill or inserting an IUD. Once the method is being used, the doctor will want to monitor progress. Medical supervision obviously includes physical examination and investigations.
Much ado has recently been made about taking a sexual history. A process akin to contact tracing has no place in the family planning consultation. Open-ended questions such as, ‘Do you think you could be at risk of HIV infection?’ are usually more revealing than closed questions such as ‘How many sexual partners have you had?’ If a doctor is very worried about the possibility of a sexually transmitted disease then the patient should clearly be referred to the genitourinary medicine clinic. Raising the subject of HIV in the consultation is relevant these days even if the patient does not feel so. A simple introduction is to mention that contraception can protect against pregnancy and infection. Methods such as barriers may do both jobs but patients and their partners will need to consider whether they need a highly effective contraceptive method combined with a barrier for protection against infection. With so much media coverage about HIV it is becoming easier to raise this subject but many patients will still feel they are not at risk.
*347/197/1*
Miss K. was a lovely girl who looked like a model, tastefully made up, a little too thin, but beautifully and elegantly dressed. The doctor felt old, untidy and frumpy. The list of contraceptive consultations was quite long, as she had started and stopped the Pill several times. At the last attendance three months previously she had given a history of being on her period and wishing to restart the Pill as she had a new relationship. A previous doctor had written rather peevishly that she refused to consider using condoms (and underlined ‘fifth partner in six years’. She had been asked to return for a cervical smear as she had not yet had one. The doctor noticed that there was no cervical smear form in the notes and started to look for one to fill in. Miss K. tipped back her head moving her long hair back slightly from covering part of her face and said, ‘Oh, didn’t you see what nurse has written? I’m on my period this week.’ The doctor looked at the record and felt quite unreasonably cross: ‘You knew that you were due for a smear; why didn’t you come two weeks ago when your appointment . . .’ and just caught herself before the accusation was completed. More gently she changed tack. ‘I notice that you’ve been coming to this clinic for six years and have managed to avoid having a smear all that time. That takes some doing!’ The girl shrugged her shoulders and did not look at the doctor, who felt another surge of annoyance. What was going on? The doctor tried again. ‘It seems to me that you might find the thought of having a smear rather frightening?’ No response except a twitch of the shoulders, turning away and excluding the doctor. She tried again. ‘Why do you think you don’t want to have a smear?’ Miss K. muttered something into her hair. The doctor had to ask her to repeat it. ‘I just don’t want it done.’ The doctor waited but nothing was forthcoming, and she pressed again, feeling frustrated, ‘I feel very shut out from what you must be feeling.’
*308/197/1*
Some women suddenly have a last minute desire for a pregnancy. They may have felt their family was complete, but sensed that their options were still open. Suddenly it seems that they are 40 and it is now or never. They may just stop their contraceptive method without medical advice. If they become pregnant and they continue to want the baby then that is fine and they present at the antenatal clinic. Other women present with side-effects regarding their method of contraception or come asking to stop it saying that they are thinking of having a baby. For others the decision may not be fully conscious and they may ask for a change to a less reliable method, for instance, from the combined oral contraceptive to the sheath, without realizing why they wish to do so. Even if they do understand what they want, they may be uncomfortable about sharing their wish with a doctor whom they imagine to have a disapproving attitude to the idea of a pregnancy later in life.
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It is common for Asian families to express a preference for a woman doctor, particularly for vaginal exarninations. This does not necessarily mean that the patient is shy or repressed sexually. Western doctors often assume, sometimes accurately, that women from the ethnic majority who are inhibited about male doctors may be generally shy about their sexuality. The same outward mannerism in an Islamic woman may be the expression only of her religious conformity, and nothing to do with her personal sexual life. This confusion has a parallel in the differences observed concerning eye or hand contact.
The organization of clinics, public notices, reception services, appointment systems and records needs to be sensitive to local needs. Texts should be translated carefully and displayed the right way up. It is an advantage if staff can be recruited from ethnic minorities. Family or address grouping of records may be useful, but it is important to watch that this does not lead to an impersonal and racist relationship where staff call for patients by their address rather than their names. The domiciliary service is an appropriate use of family planning nurses for women who are less mobile because of larger families, fear of racial harrassment or who find it socially and practically difficult to go out without their husbands who are working long hours. The home visit, by its visibility, is an advertisement for local services to neighbours and friends.
*232/197/1*
Tom Smith is in his 30s and is a professional man. He developed multiple sclerosis some years ago. The disease has been progressive and increasingly incapacitating. He has had to give up work as he is now unable to cope physically with the demands on him. The stress of the illness has put a strain on his marriage and he is now divorced. He is very distressed at the loss of his children.
He became unable to look after himself and went back to the parental home where his parents cared for him, indeed smothered him. He felt he was treated as a child. In addition to needing physical care like a child, such as washing and toileting, he felt put down and emasculated. He could not see how he could live out the remainder of his life like this.
He arrived to see the doctor in a wheelchair. The disease had resulted in total inability to walk and in some loss of hand function. In addition his speech was affected. This meant he had to take a deep breath and run his words out in little quick bursts which exhausted his energy, and he had to rest and start again. The doctor’s technique of asking an open-ended question and allowing the patient to talk at length was thus unusable. Comments had to be phrased in a more direct way so that he could make short replies. The doctor needed to try to pick up on his feelings so that he could either accept or reject any assumptions made. It was clear that he found this enabling and the doctor was conscious of the need to allow him to be a man, and be treated like one, with difficult issues addressed and not evaded or ignored.
He very much wanted to utilize the remainder of his life, hopefully with a sexual relationship, but was diffident about the response he would get as he was not ‘a good catch’. One day the doctor commented, ‘Only the outside of you is changed, the old you is still there inside.’ His smile lit up and he said, ‘Too right – on the button.’ This recognition was very important to him. His mind was crystal clear, only his body would not respond to his demands on it. His need for independence was discussed and he eventually found sheltered accommodation where he was again able to take responsibility for much of his own life. He has since met a partner and has a happy relationship.
*193/197/1*
