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While the patient is talking, one begins to get a feel about the patient. One may hear snippets about their partner, the family or the workplace and begin to understand their feelings about sex and contraception. Family intentions are very important and relevant to the discussion of different methods. Listening carefully may reveal the sort of conflicts mentioned earlier in this book.
A common practice in family planning clinics is for patients to see the nurse for history-taking and then go in to see the doctor. While fully acknowledging that many patients develop rapport with nurses better than with doctors, this split type of consultation can have disadvantages. Highly trained nurses can run their own consultations independently (the so-called delegation session) unless a medical problem arises or an IUD insertion is required.
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Miss B. originally attended with her partner for a new patient interview. They were an incongruous pair: he was grubby with a marked local accent, wearing torn jeans and with his hair in a pony-tail, while she was a slim, neat girl with a well-educated voice. He did all the talking and was concerned because she was always feeling ill. Some tests were arranged and the doctor was relieved when she reattended by herself. Miss B. ignored the test results and reassurance offered. Her boyfriend had told her to get a coil fitted. She said that after the enquiries at the last consultation (when he had assured the doctor that contraception was not a problem), he had thought about it and decided that as he did not want any children about the place, she had better get fixed up. Suggestions that she might have some opinions or feelings about it were met with a look of incomprehension and after battling for a while – ‘I must have a coil today’, she kept saying – the doctor gave her some leaflets to read and arranged to see her with her period the following week. At that consultation, she arrived in complete distress, her boyfriend having been picked up in possession of drugs. Decisions were postponed. Next time she was more composed and ‘they’ had decided she would go back on the Pill, which she had taken ‘for several years’. Further enquiry revealed that her boyfriend was on remand and likely to be sent to prison. Naively the doctor enquired why contraception was necessary, only to discover that Miss B. lived in a multi-occupied house and without her boyfriend’s presence would be expected to be available to the other men living there. The doctor, sure by now that there were deep underlying problems, probed and listened and encouraged until the girl, relaxed and open, was able to reveal that she had been dominated totally by her authoritarian solicitor father and sexually abused by him until she was 20. She had then met her present boyfriend through her black sheep brother who had rebelled against her father and was into drugs and various criminal activities. She had been thrown out of her home only to join another abusive environment, and had no idea
of how to take control over her own life or sexuality. She saw herself as available to be used and only considered contraception as a necessary part of this.
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Straightforward advice about the safety of combined oral contraception in the low-risk woman until the age of 45 or more can be sufficient, and the safety of the progestogen-only Pill up to the menopause is well known. Reassurance that the IUCD can often be retained longer than five to six years may put the patient’s mind at rest. Someone who has used the cap with no difficulty and is now in her 40s is unlikely to conceive with this method.
For those women whose partners have successfully used a sheath for many years, a failure is very unlikely, and a request for a change of method may be an indication of some other problem. For a man who is suffering some degree of impotence, the need to stop to put on a condom can be the last straw. If a woman is requesting contraception for the first time, or after using other methods for a long spell, or perhaps with a new partner, the sheath may be a little risky, especially if she is very definite about her need to avoid a pregnancy.
If the patient is allowed to express the feelings that have brought her to the consultation, reassurance and explanation may be sufficient. However, if her anxieties are not related directly to the method, the underlying difficulties should be explored further.
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Among the commonest interpreters available for immigrant couples are their children. These are the least suitable in my view. Either the clinician limits his enquiry severely, to spare the child distress, or, inured to the vulnerability of non-white children, he uses them indiscriminately. In the experience of Tower Hamlets general practitioners, stress-related illness has a high prevalence in Bengali children, and the role of go-between must increase their anxieties. Husbands who have preceded their wives to the UK often have sufficient English language skills to interpret. Such help for the woman is still quite different from having access to an impartial translator of her words, and there is a confusing overlap in the triangular consultation. The problem cannot be solved easily by bringing in an independent translator. Our own antenatal clinic was served by Bengali women who had been trained to act as interpreters for maternity services. Husbands of the pregnant women would usually ask them not to come in to the consulting room, for if they did the husbands saw that as a very obvious mark of their own inadequacies. Immigrants from a village culture are also understandably wary of the network of gossip.
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If patients have problems with mobility or mental handicap it may be necessary to see them on their own territory when familiar surroundings can provide a greater sense of security. Few general practitioners will have any difficulty in the home environment, but for other doctors the loss of the secure consulting room setting can increase their sense of unease.
If the doctor feels overwhelmed by the size of the problem it can be valuable to break it down into smaller parts, remembering that ‘the longest journey starts with a single step’. The areas of need can be divided into three parts; emotional needs, physical or practical needs (that is, ‘how to do it’) and contraceptive needs.
The first two areas of need may appear more difficult and may arouse more anxieties because, if the patient is able to achieve sexual intercourse, then the whole question of the advisabilty of pregnancy and the need for contraception will follow.
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LOVE OF ALL HUMANKIND AND THE WHOLE WORLD
Author: admin
The Ancient Greeks saw this as the highest plane of love. From the security of having been loved as a baby and child, from loving oneself and being confident that one is lovable, and from having a mature love for another adult comes the ultimate – the maturity of love that enables an individual to extend all these feelings to mankind in general. This is no longer an adolescent ‘change the world’ form of love but one forged from the experience that life cannot and will not go the way you want it to; that everyone has their rights and points of view; and that yours have to fit in with those around you. At this stage you can love those that persecute you; you can turn the other cheek and no longer retire hurt or angry when the world refuses to go your way. Such love is the Christian love of the New Testament in which one loves one’s neighbour as oneself. People in this stage of love really do change the world and contribute to it. The mature adult at this stage expresses his or her general love in specific ways – often with powerful effects.
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Western women spend millions of pounds and hours in removing hair they believe to be unsightly. Hair on the upper lip, on the limbs, around the nipples and up the abdomen and extensions of the pubic hair to the top of the thighs are all common but sometimes unwelcome. Men and women have about the same number of hairs – the real difference is in the type of hair at different locations and its visibility. Hairiness in women is occasionally the sign of the presence of disease but is mainly genetic in origin. Some men prefer hairy women and claim they are more sexy than others. Apart from electrolysis or periodic plucking of unwanted hairs, shaving is probably as good a solution as any for these women who are upset by the hair. Chemical depilatories are also very widely used. Indeed, female body hair removal is a
multi-million pound business.
Monthly check-up-Most women are understandably afraid of contracting breast cancer and it makes sense to detect a breast lump as early as possible so that it can be treated. It is best to feel your breasts for lumps regularly each month using the same routine a day or two after your period has stopped. Get to know how your breasts feel during other times of your menstrual cycle too and always report any suspicious lumps to your doctor. A delay could make treatment more difficult.
If you have an IUD pop a finger into your vagina each month the day your period stops to check that the tail of the device is still coming out of the cervix. If you can’t feel it, take other contraceptive precautions and see your doctor at once to have a new one put in if necessary.
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PROSTITUTION: CLIENTS OF PROSTITUTES
Author: admin
The clients of prostitutes are said to come from all walks of life but increasingly come from the older segment of the community because free sex, it is said, is more easily available to the young today than in the past. Older men, especially if they are concerned with their respectability, are often unwilling to make advances to women of their acquaintance and may be happier to patronise prostitutes. Older husbands are more likely to be sexually bored with their partner than are younger men and are often less willing to run the risks of emotional entanglement with a non-prostitute. Men with more ‘deviant’ needs, with physical handicaps, or with a penis they regard as unusually small, may all be more attracted to prostitutes rather than face rejection, or exposure, by a non-prostitute. If you are paying the woman (they argue) she cannot refuse you. This is not in fact true and prostitutes will refuse clients with whom they do not feel safe or who do not fulfil other criteria.
Because prostitutes are available in all age groups and in all variations of body-form and colour, the patron of prostitutes can choose what he wants, as opposed to picking from what happens to be available in the non-prostitute population he meets. Some men who have been reared to believe that sex is unacceptably sinful can only get normal sexual pleasure when with a prostitute and some men who are emotionally immature may prefer prostitutes to other women.
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SEX-RELATED DISEASES: GONORRHOEA
Author: admin
This is the second most common of the ‘real’ venereal or sexually transmitted diseases (STDs). It is in sharp decline due to the AIDS scare leading to safer sex in homosexuals and to a lesser extent in others.
Gonorrhoea is caused by a germ called a gonococcus which is mainly transmitted by sexual intercourse. It is possible to catch the disease via infected towels and other household items and this is the way babies and young children sometimes catch it. The bacteria grow in and on the sexual organs but they can also grow in the throat (after oral sex) and rectum (after anal sex). Homosexual men are very likely to get gonorrhoea. If you have sex with someone who has the disease you stand a 70 per cent chance of getting it, but the risk is greatly reduced if the man wears a condom. If a man urinates immediately after intercourse with an infected woman he stands a fair chance of escaping infection.
The symptoms differ considerably in the two sexes. In men they are usually fairly obvious. A few days after intercourse with an affected woman or man the man has a severe burning pain when passing urine and then develops a yellow discharge of pus from the penis. These symptoms must be taken seriously, so go to your doctor or local clinic at the hospital at once. Early treatment will not only cure the disease and stop it spreading to anyone else but will also prevent longterm complications of the disease, such as eye trouble, arthritis, painful swelling of the testes, or a narrowing of the urethra (urinary passage).
Unfortunately, as many as half of all women with the disease have no symptoms and as a result may infect others unknowingly. This is why gonorrhoea is such a widespread disease and is so difficult to eradicate. Others get the same sort of symptoms as men but the gonorrhoea also affects the fallopian tubes and ovaries. These can also become inflamed and produce lower abdominal pain, fever, menstrual irregularities and a vaginal discharge. Later still the fallopian tubes may become blocked off and the woman is then infertile.
Treatment is relatively simple and effective and if started early prevents the long-term effects we have outlined. It is really best to go to an STD clinic or to your doctor if you have any suspicion that you have this disease or if you have had intercourse with someone you suspect could have it. Simply ring your local hospital and ask for the; ‘Special Clinic’. Such clinics maintain absolute secrecy and discretion, and your partner or parents (if you are a teenager) will never be contacted without your permission. There is no need to give a false name as many young people do. If you have any symptoms that could be gonorrhoea, don’t have sex of any kind until you have been checked over by a doctor. Almost every infection caught early can be cured.
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Are pets any help?
Yes. By having pets and watching them mate and have their young, children of all ages can learn a great deal about sex in a gentle, natural way. Of course, watching rabbits teaches nothing about human inter-relationships but it helps get the plumbing sorted out in their minds and this in itself is a help. Research shows that country children are much more at ease with physical sexuality and that this is probably because their experience of animal sex has made them see the whole thing as natural and normal, which it is.
How useful are books for children?
That depends on the book and the child. Some children are happier to learn from books than from adults, so for them a good book can be just the job. There are lots of good books around for children of all ages, but be sure to read any book first so that you know what your children are learning. If there are things you do not like about the sex-education books they use at school, take up the subject with the head teacher. There are books available for parents to read with their children and this can be a very good way of handling the subject.
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