Medical Articles, Medicine Information.

Balint (1957) was the pioneer of the study of interactions between doctors and patients, and his group training methods have been used widely. Originally, the groups were led by psychoanalysts who were not themselves general practitioners, and whose concern was not the teaching of general practice, but the running of a group where problems met by general practitioners could be studied. Within the Institute of Psychosexual Medicine, Main has extended Balint’s ideas by training doctors experienced in psychosexual medicine, who are not themselves psychoanalysts, to be the leaders of groups where the question of psychosomatic sexuality can be studied.

The method of training is based on case discussion of the member’s ongoing clinical work, and is aimed at developing skills rather than instilling knowledge (Main, 1983). Group members may be disappointed at the length of time it takes to acquire new attitudes and skills. It is important to stress that these groups are not for supervision, where members come for advice about what to do with their patients, but opportunities to think afresh about what is going on in the consultation. The responsibility for the management of the patient remains with the doctor at all times.

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There are the constraints provided by the doctor. The doctor may feel unable to give help because of an awareness of lack of aptitude or skill. Or doctors may find that personal feelings are interfering with the proper objective management of the problems, particularly if similar problems have been experienced personally or to someone emotionally close to them. For example, it may be too distressing to cope with a patient complaining of lack of libido after a miscarriage of a wanted baby if the doctor or the doctor’s wife has recently suffered the same misfortune. It may be impossible to deal with a patient giving a history of sexual abuse if the doctor finds that personal memories and distress are re-awakened. Sometimes social contacts may also make it necessary for doctors to distance themselves from the problem. It is not a good idea, for instance, to take on one’s colleagues for therapy, however much they may want to keep it ‘in the family’. Friends and acquaintances are not well served by agreement to help them informally – a referral to a colleague where a proper patient/therapist relationship can maintain professional standards is in everybody’s best interest.

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The relevance of tensions within a family to a particular sexual difficulty cannot be guessed by the doctor and may not have been appreciated by the patient until she or he can talk freely about whatever comes to mind. Then the listening doctor may be able to make the connection with the patient and they can continue to work together to resolve the problem.

Some people are only too delighted to be able to put the fear of pregnancy behind them and embark on a sexual life free from the nuisance of contraception. For others, as has been suggested, the ambivalence about making the change to the next phase of life can cause problems. At the present time there is often a gap between the onset of menopausal symptoms and the moment when natural infertility can be assured. It is to be hoped that it will not be long before there are hormonal preparations that will allow this gap to be filled more smoothly.

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Now is the time to be particularly aware of the possibility of marital stress, and to watch for any sign of one partner being manipulated by the other. Counselling in depth is not needed by all couples, but there is a much higher incidence of regret among those who are sterilized at a younger age, or at a time of emotional stress. These problems are considered in more detail in the sections that follow.

Perhaps as many as 10% of women regret the operation, and the concept of good care must include an attempt to identify those people at risk of regret before the operation is undertaken. When sterilization is being discussed it is wise to ask both partners to consider how they would feel if their marriage broke down, or if they lost a child, although the reply is almost invariably that they feel they could never replace that particular child. Such a reply may make the doctor feel rebuffed, but it may help the couple to look again at the irreversibility of the operation. Another approach is to enquire how each will feel when their partner is sterile, and to consider which partner might grieve least for their fertility.

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If contraception is required then again the biggest problem can be the doctor’s assumptions about what method is suitable for an individual. When advising on contraception, the skill lies in matching the method to the patient’s needs, preferences and lifestyle, within the limits set by certain medical considerations such as absolute contraindications. Where a disability exists, the type of doctor/patient relationship which may develop and the attitudes to the disability may encourage a more authoritarian style, and the doctor needs to recognize this so that the choice remains with the patient. The prescriber will be assessing the usual indications and contraindications for the methods, weighing up the advantages and disadvantages with the patient, but it is useful to ask oneself in addition, ‘What skill is required to use this method?’ Is it a question of having a good memory, manual dexterity or mobility? It is vital to establish good communication with the patient so that understanding is ensured, especially if there is blindness, deafness or mental handicap. To find a way through a complex set of problems the following maxim is useful: ‘How does the disability affect the contraception, and how does the contraception affect the disability? When both of these sides of the equation are satisfactorily answered, one has a possible choice of method.

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