Problems in the male partner after childbirth may have a significant influence on the quality of the couple’s sexual relationship. These problems may be caused by many different factors, some of which will not be fully conscious. A study of the doctor/ patient relationship may provide a clue to the problem. Sometimes the couple are unable to express their feelings openly because of anger or fear of hurting each other. For the family planning doctor the problems may be expressed as difficulties with contraception, or the disturbed sexual relationship may make contraceptive decisions difficult. Where problems in the male partner are acknowledged or suspected, an offer to see him or the couple together can be helpful.

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The rhythm method implies a great deal of control but is poorly understood by many men. Several of those spoken to thought the rhythm method meant withdrawal. Once clarified, it was clear that there were many misunderstandings. The days after menstruation were regarded as safer than those before. However, those couples who did use it seemed to share their understandings and were happy. As expected, these were couples with a keen desire for the natural, or strong religious beliefs. They were aware of confusing medical advice on timings, and had their own feelings about what was safe despite the advice. Usually both the man and the woman knew when she ovulated, and this closeness was apparent in discussion. ‘It puts a brake on us’, said one man. ‘If we have been cross with each other, she doesn’t always ovulate, and then we have to wait.’

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Contraception is often considered to be just about stopping babies, but it also says a great deal about having a good sex life without the fear of a pregnancy. Why are doctors so afraid to bring up the topic of sex with their patients when discussing contraception? It is so important to elicit possible problems early on. Is she wanting a good sex life with no babies? Is she wanting to delay her family until the ‘right time’, and also have a good sex life? Is she wanting to enjoy an active sex life with her partner without the obvious responsibilities that a baby will produce, at the present time or maybe forever? Is she having a sex life at all – or is it just that everyone else takes the Pill when they are in a stable relationship, engaged or getting married? The assumption that sexual intercourse has taken place when the woman has been on the Pill for many years is common, but it is not always justified, and appropriate comments or questions to clarify the situation should be mandatory.

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The provision of the best possible care for young people in today’s society, with pressure towards sexuality coming not just from the internal forces towards maturity which have always been present, but also from the peer group and, most strongly, from the media, is not easy for the professional. There is an over-riding need to provide the practical help necesssary to reduce the risks in an atmosphere that is acceptable to the patient, as has been described in this chapter. Considerable skill is needed to allow the patient to feel that her sexuality is allowable and valuable, while at the same time warning her of the health risks.

What, then, of the more general health education that is offered to other patients? The family planning consultation is seen as an ideal opportunity to broach such subjects as smoking and obesity, but the young person may feel such advice to be ‘yet another lecture’. If given unthinkingly, she or he may be antagonized so that they stop coming for the contraceptive help which is so desperately needed. However, if given sensitively and at an appropriate time, the assumption that she or he is now grown up enough to want to look after themselves can enhance self-esteem.

Perhaps the most difficult dilemma for the doctor, as for young people themselves in the age of AIDS, is to reconcile the strong, inevitable and healthy emotional and sexual drives, with the possible risk of serious damage to their health or even death. The equation

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‘I want a health check,’ she commanded, forceful and unsmiling. Doctors and nurses are not used to being ordered about in this way; it is easy for hackles to rise and defences to spring up. The doctor felt attacked and was tempted to retaliate, to point out that this was family planning, not a well woman clinic, for example. Instead, she inwardly observed this difficult atmosphere, and wondered what was behind it. ‘We haven’t seen you for some time,’ she commented. Mrs A. shrugged, but remained silent. ‘Are you still on the Pill?’ ‘No,’ another shrug, then defiantly, ‘We use a sheath.’ The tension level in the room rose. ‘Look, I’ve come for a health check – that’s all!’ The doctor thought to herself, ‘Contraception produces tension, but is not to be discussed.’ She changed tack. ‘Of course we will examine you. Have you been having any problems?’ Immediately, the reply shot back, ‘No.’ Another glare at the watch. The doctor sat back and waited, refusing to be bounced into this checkup, realizing that, so far, she had been doing the work here. Now she let the patient decide how to continue.

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