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A male doctor was faced with a patient whose calling card was a rather vague account of irregular bleeding on the Pill. The doctor noticed that she seemed rather withdrawn and unhappy. In response to a general enquiry about other worries she began to tell him about the sexual abuse she had suffered from her father in her early teens. Suddenly the doctor noticed that she appeared overwhelmingly attractive. The strength of his feelings in response made him stop listening to what she was saying. He reported to the group that he was able to recognize his own feelings, and the fact that they had stopped him listening. He managed to say nothing to the patient, and resolved to make himself listen to her story some more. Gradually, the sense of sexiness wore off, and by the end of the consultation he felt comfortable enough to consider the possibility of a genital examination without anxiety.

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Referral should take place after mutual agreement between the patient (who is complaining) and the doctor. The purpose is to obtain a specialist opinion, or investigations or treatment not available from the referring doctor. Reluctance or even resistance will be encountered if the patient has been sent by another person, such as the partner, for treatment, when they do not perceive that they have a problem (as with Mr S.). It might be possible to suggest to a partner that the patient complaining will need the assistance of that partner in the therapy, thus engaging their interest at the outset.

However, if the doctor insists on referring both partners when only one is complaining, there may be serious difficulties for the therapist to whom the couple are referred. Both partners need to accept an adult and responsible role during therapy. The therapist offers interpretation and suggestions about changes, but it is up to the individuals to make use of them. More often, a therapist, whether using cognitive therapy, behavioural techniques or psychotherapeutic interpretations, will empathize with the person who seeks help for the problem. A partner who has not acknowledged that he or she has a problem is much harder to engage in therapy, and may opt out by not attending either physically or mentally, or even undermining therapeutic endeavours in a subtle fashion.

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The older age groups may also be reluctant to reveal their sexual activity to their regular medical attendants (or their staff), but for slightly different reasons. They may not wish to bother their doctors – who they view as caring for ill people – with their contraceptive needs which they feel are less important. They may fear that their sexuality is not acceptable to their doctors, to the staff or to other patients whom they encounter in the surgery and who may enquire why they are attending. One woman in her 40s travelled many miles to attend a clinic far from her home. Married to the minister of a strict religious sect, she could not risk revealing to her husband’s flock that she was sexually active and needed to use a diaphragm to prevent pregnancy. She could not refuse him intercourse, nor did she wish to do so, although she felt it was somehow wrong and sinful not to be above such base human emotions. She feared further pregnancy with advancing years, but saw her need for contraception as a betrayal of her husband’s teaching which had to be concealed from his congregation. Her ambivalent attitudes had made her an unpopular patient at the family planning clinic she attended; she had managed to make most of the staff feel that they were somehow dealing in something unsavoury and undesirable.

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Counselling did help this couple towards an acceptance of their situation, but years of suffering might have been avoided if they had been encouraged to make a joint decision regarding their future together when the wife had recovered from her third delivery. However, it must be recognized that it is easy to be wise after the event, and with hindsight the patient may find it easy to blame the doctor for inadequate discussion. At times of stress people do not really hear those things that they do not wish to hear, as the following case demonstrates.

A married couple attended the subfertility clinic over a period of several years. As time passed the anguish of the woman and the grief of the husband became increasingly distressing. The man was in his 50s, tall, distinguished and successful. He had agreed to a vasectomy in his first marriage because his wife suffered from a severe depressive illness which recurred after each childbirth. He had felt that she had suffered so much that he should have the operation. His wife died some 10 years after the vasectomy and after a time he had remarried a much younger woman. They both wished for children, and he underwent reversal of vasectomy.

This man was totally unprepared for the very poor semen analyses after reversal. He felt that he had not understood that the operation should be regarded as irreversible when the vasectomy was discussed. He did volunteer that he had been under considerable stress at the time, and he felt now that it would have been more appropriate if his wife had been sterilized as she could not have had another pregnancy safely. At the time he had felt she had suffered enough.

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A group of people who have particular need are those who are terminally ill. If sexuality and disability are difficult words to put together, then sexuality and dying are even more so. This is an emotional time with many issues to be addressed. Among these, personal relationships are sometimes overlooked. The worries of both doctor and patient over what people may think if these needs or difficulties are acknowledged can be acute. When time is of the essence people need to use it in whatever way seems important to them. Increasing incapacity and the loss of part of their life which has always been important to them matters a great deal. They do not appreciate being put on a waiting list for psychosexual counselling. They need swift and appropriate attention so that they can utilize their remaining time together in the best way, feeling free to use what physical contacts are available to them to maintain and develop the fullest possible relationship to the end.

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